Healthcare Provider Details

I. General information

NPI: 1902105646
Provider Name (Legal Business Name): KANAYO TATSUMI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CLARK AVE
SAINT LOUIS MO
63103-2718
US

IV. Provider business mailing address

1300 CLARK AVE
SAINT LOUIS MO
63103-2718
US

V. Phone/Fax

Practice location:
  • Phone: 314-622-4971
  • Fax: 314-977-7615
Mailing address:
  • Phone: 314-622-4971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number278417
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2019024496
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number278417
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number2019024496
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: