Basic Information
| Provider Information | |||||||||
| NPI: | 1134193162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHATTACHARYYA | ||||||||
| FirstName: | ANJAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1438 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149774828 | ||||||||
| FaxNumber: | 3149774877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1438 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149774850 | ||||||||
| FaxNumber: | 3149774876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34489 | IA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | 34489 | IA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 07172008 | 05 | MO | MEDICAID | 48914 | 01 | IA | WELLMARK BCBS | OTHER |