Healthcare Provider Details

I. General information

NPI: 1871521054
Provider Name (Legal Business Name): TANEEMUL HAQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

325 W WATERS EDGE DR
BELLEVILLE IL
62221-7835
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax: 314-289-7612
Mailing address:
  • Phone: 314-652-4100
  • Fax: 314-289-7612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number017104
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: