Healthcare Provider Details

I. General information

NPI: 1932424850
Provider Name (Legal Business Name): NIKHIL BANERJEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2010
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11525 OLDE CABIN RD
SAINT LOUIS MO
63141-7146
US

IV. Provider business mailing address

11525 OLDE CABIN RD
SAINT LOUIS MO
63141-7146
US

V. Phone/Fax

Practice location:
  • Phone: 314-997-0554
  • Fax: 314-997-5086
Mailing address:
  • Phone: 314-997-0554
  • Fax: 314-997-5086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number39347
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036132434
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2018019584
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: