Healthcare Provider Details

I. General information

NPI: 1912742958
Provider Name (Legal Business Name): RAN HAZAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/11/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WUSM PEDS, 1 CHILDRENS PL, MSC 8208-0016-06
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

WUSM PEDS, 1 CHILDRENS PL, MSC 8208-0016-06
SAINT LOUIS MO
63110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6124
  • Fax: 844-616-1418
Mailing address:
  • Phone: 314-454-6124
  • Fax: 844-616-1418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2024025058
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: