Healthcare Provider Details

I. General information

NPI: 1417040114
Provider Name (Legal Business Name): TONY THIEN TANG M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4675 SOUTH GRAND BLVD.
ST. LOUIS MO
63111
US

IV. Provider business mailing address

4675 SOUTH GRAND BLVD.
ST. LOUIS MO
63111
US

V. Phone/Fax

Practice location:
  • Phone: 314-752-8600
  • Fax: 314-752-8601
Mailing address:
  • Phone: 314-752-8600
  • Fax: 314-752-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2003024222
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: