Healthcare Provider Details

I. General information

NPI: 1932490273
Provider Name (Legal Business Name): POORIA SALARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 12/21/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8233
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-2500
  • Fax:
Mailing address:
  • Phone: 314-747-2500
  • Fax: 314-747-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number2017013931
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: