Healthcare Provider Details

I. General information

NPI: 1538399878
Provider Name (Legal Business Name): TAGANN CHAISAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax:
Mailing address:
  • Phone: 314-977-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number2008026682
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: