Healthcare Provider Details

I. General information

NPI: 1124007380
Provider Name (Legal Business Name): VADIM YURI BARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 OLD OLIVE STREET RD STE 205
SAINT LOUIS MO
63141-5914
US

IV. Provider business mailing address

10420 OLD OLIVE STREET RD STE 205
SAINT LOUIS MO
63141-5914
US

V. Phone/Fax

Practice location:
  • Phone: 314-504-4698
  • Fax: 314-692-9978
Mailing address:
  • Phone: 314-504-4698
  • Fax: 314-692-9978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2004022302
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2004022302
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: