Healthcare Provider Details

I. General information

NPI: 1669445508
Provider Name (Legal Business Name): PHILIP VAIDYAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 09/14/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S GRAND BLVD
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

DIVISION OF GENERAL INTERNAL MEDICINE, ROOM 2717 1008 SOUTH SPRING
SAINT LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5060
  • Fax: 314-977-1664
Mailing address:
  • Phone: 314-977-5060
  • Fax: 314-977-1664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2005017816
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2005017816
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: