Healthcare Provider Details

I. General information

NPI: 1073891552
Provider Name (Legal Business Name): PRITYI RANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL PLZ STE 221
LAKE ST LOUIS MO
63367-1483
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-625-6041
  • Fax:
Mailing address:
  • Phone: 636-498-5973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2011013993
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: