Healthcare Provider Details

I. General information

NPI: 1922032994
Provider Name (Legal Business Name): INFECTIOUS DISEASE CONSULTANTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 70B
SAINT LOUIS MO
63141-8251
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 70B
SAINT LOUIS MO
63141-8251
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-5700
  • Fax:
Mailing address:
  • Phone: 314-251-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberR4F74
License Number StateMO

VIII. Authorized Official

Name: DR. FARRIN A MANIAN
Title or Position: PRESIDENT
Credential: M.D., MPH
Phone: 314-251-5700