Healthcare Provider Details

I. General information

NPI: 1972521490
Provider Name (Legal Business Name): SURENDRA SHENOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/25/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DIV SURG TRANSPLANT, STE 12B
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 60352
SAINT LOUIS MO
63160-0352
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-9889
  • Fax: 314-361-4197
Mailing address:
  • Phone: 314-747-9889
  • Fax: 314-361-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number106430
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number106430
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: