Healthcare Provider Details

I. General information

NPI: 1124010772
Provider Name (Legal Business Name): SAMUEL A CHANDRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8054
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3581
  • Fax: 314-747-1710
Mailing address:
  • Phone: 314-747-3581
  • Fax: 314-747-1710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number114178
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.109888
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: