Healthcare Provider Details

I. General information

NPI: 1043754039
Provider Name (Legal Business Name): TARIQ HALASA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TARIQ K HALASA MD

II. Dates (important events)

Enumeration Date: 12/09/2016
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

232 S WOODS MILL RD
CHESTERFIELD MO
63017-3485
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5772
  • Fax:
Mailing address:
  • Phone: 314-434-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2021026797
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number2021026797
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number25MA12122800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: