=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487184859
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIRIVAN SUON SENG M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 11/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10012 KENNERLY RD STE 406
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-2197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-525-1224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10012 KENNERLY RD STE 406
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-2197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-525-1224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086P0122X
-----------------------------------------------------
Taxonomy Name | Physician Nutrition Specialist (Surgery)
-----------------------------------------------------
License Number | 2025017589
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 2025017589
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------