Healthcare Provider Details

I. General information

NPI: 1407734544
Provider Name (Legal Business Name): FNU EHTISHAM-UL HAG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD ST. MARY'S HOSPITAL-ST. LOUIS DEPT OF INTERNAL MEDICINE 2ND FLOOR
ST. LOUIS MO
63117
US

IV. Provider business mailing address

6420 CLAYTON RD ST. MARY'S HOSPITAL-ST. LOUIS DEPT OF INTERNAL MEDICINE 2ND FLOOR
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 Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2025024125
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: