Healthcare Provider Details

I. General information

NPI: 1619382355
Provider Name (Legal Business Name): CHIKE AUGUSTINE ILORAH M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE RM 3723
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax:
Mailing address:
  • Phone: 314-977-3129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number0101281137
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number44202
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number2019011182
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberFT533
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number036149769
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036149769
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: