Provider Demographics
NPI:1194783068
Name:SANJAY A. PATWARDHAN, MD, PC
Entity type:Organization
Organization Name:SANJAY A. PATWARDHAN, MD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATWARDHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-909-4700
Mailing Address - Street 1:PO BOX 952037
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2037
Mailing Address - Country:US
Mailing Address - Phone:636-566-8155
Mailing Address - Fax:636-566-8732
Practice Address - Street 1:13610 BARRETT OFFICE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63021-7816
Practice Address - Country:US
Practice Address - Phone:314-909-4700
Practice Address - Fax:314-909-4712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508330206Medicaid
MO508330206Medicaid