Healthcare Provider Details

I. General information

NPI: 1649825902
Provider Name (Legal Business Name): SANKET SRINIVASA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL STE 8C
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

660 S EUCLID AVE CAMPUS BOX 8109
SAINT LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-0410
  • Fax:
Mailing address:
  • Phone: 314-747-0410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2019011878
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: