Basic Information
| Provider Information | |||||||||
| NPI: | 1306907738 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | QAYUM | ||||||||
| FirstName: | TAHIR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9735 LANDMARK PARKWAY DR | ||||||||
| Address2: | STE 220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631271646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435942 | ||||||||
| FaxNumber: | 3145435947 | ||||||||
| Practice Location | |||||||||
| Address1: | 12700 SOUTHFORK ROAD | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145435942 | ||||||||
| FaxNumber: | 3145435947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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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 | 208D00000X | 106241 | MO | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | 11011 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208093419 | 05 | MO | MEDICAID |