Healthcare Provider Details

I. General information

NPI: 1194139113
Provider Name (Legal Business Name): COLLIN CHEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 03/05/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S. GRAND DOOR 3
ST. LOUIS MO
63104-6310
US

IV. Provider business mailing address

1008 SOUTH SPRING AVENUE DEPARTMENT OF OTOLARYNGOLOGY
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-5110
  • Fax:
Mailing address:
  • Phone: 314-977-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2014016666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: