Healthcare Provider Details

I. General information

NPI: 1174043301
Provider Name (Legal Business Name): CHENG XIN JIANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 200
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 200
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5942
  • Fax: 314-543-5947
Mailing address:
  • Phone: 314-543-5942
  • Fax: 314-543-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2017018674
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: