Basic Information
| Provider Information | |||||||||
| NPI: | 1194932996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | FANGXIANG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10012 KENNERLY RD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435999 | ||||||||
| FaxNumber: | 3145435994 | ||||||||
| Practice Location | |||||||||
| Address1: | 10012 KENNERLY RD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435999 | ||||||||
| FaxNumber: | 3145435994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | R-7468 | IA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 39180 | IA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 43769 | AZ | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 2011015498 | MO | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 156440052 | 01 | MO | MEDICARE PTAN | OTHER |