Healthcare Provider Details

I. General information

NPI: 1124086038
Provider Name (Legal Business Name): RAHUL S PHATAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

IV. Provider business mailing address

3015 N BALLAS RD
SAINT LOUIS MO
63131-2329
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5772
  • Fax: 314-996-7691
Mailing address:
  • Phone: 314-996-5772
  • Fax: 314-996-7691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2001009343
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: