Healthcare Provider Details

I. General information

NPI: 1750945556
Provider Name (Legal Business Name): SAMRAT JUN JAYANTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date: 12/23/2019
Reactivation Date: 01/11/2020

III. Provider practice location address

6420 CLAYTON ROAD, SSM HEALTH ST MARY'S HOSPITAL
ST. LOUIS MO
63117
US

IV. Provider business mailing address

6420 CLAYTON ROAD, SSM HEALTH ST MARY'S HOSPITAL
ST. LOUIS MO
63117
US

V. Phone/Fax

Practice location:
  • Phone: 314-768-8778
  • Fax: 314-768-7101
Mailing address:
  • Phone: 314-768-8778
  • Fax: 314-768-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2022027534
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2022027534
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: