Healthcare Provider Details

I. General information

NPI: 1275218802
Provider Name (Legal Business Name): SURAJ SHANKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLAZA
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE MSC 8134-17-2000
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-2462
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023024574
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: