=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992324214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. AVI GANDHI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2020
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S GRAND BLVD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63104-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-577-8637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10362 OLD OLIVE STREET RD APT 409
-----------------------------------------------------
City | CREVE COEUR
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63141-5942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-558-5037
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 2023026716
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------