Healthcare Provider Details

I. General information

NPI: 1154484673
Provider Name (Legal Business Name): MIRIAM B RODIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 11/04/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 DELMAR BLVD
SAINT LOUIS MO
63112-2617
US

IV. Provider business mailing address

1008 S SPRING AVE FL 2
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-7848
  • Fax:
Mailing address:
  • Phone: 314-977-8462
  • Fax: 314-771-8575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2007030792
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036076819
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2007030792
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: