Healthcare Provider Details

I. General information

NPI: 1326059957
Provider Name (Legal Business Name): BAHAR BASTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/04/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AMBULATORY CARE CENTER 1225 S. GRAND BLVD
ST LOUIS MO
63104-1016
US

IV. Provider business mailing address

SLUCARE ACADEMIC PAVILION 1008 S. SPRING
ST LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8765
  • Fax: 314-771-0784
Mailing address:
  • Phone: 314-973-4994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR7H14
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: