Healthcare Provider Details

I. General information

NPI: 1770743189
Provider Name (Legal Business Name): VADIM BARAM MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10420 OLD OLIVE STREET RD STE 205
SAINT LOUIS MO
63141-5937
US

IV. Provider business mailing address

10420 OLD OLIVE STREET RD STE 205
SAINT LOUIS MO
63141-5937
US

V. Phone/Fax

Practice location:
  • Phone: 314-692-8516
  • Fax: 314-692-9978
Mailing address:
  • Phone: 314-692-8516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2004022302
License Number StateMO

VIII. Authorized Official

Name: CAREN ZINN
Title or Position: OFFICE MANAGER
Credential:
Phone: 314-692-8516