Healthcare Provider Details

I. General information

NPI: 1265421218
Provider Name (Legal Business Name): SIROTH CHARNOND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 UNION BLVD
SAINT LOUIS MO
63115-1142
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 314-888-0970
  • Fax: 314-408-7063
Mailing address:
  • Phone: 314-888-0970
  • Fax: 314-408-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number108377
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.150546
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: