Basic Information
| Provider Information | |||||||||
| NPI: | 1386865822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISHIYAMA | ||||||||
| FirstName: | TAKAAKI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | SLU CARE ACADEMIC PAVILION | ||||||||
| Address2: | 1008 SOUTH SPRING | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142578222 | ||||||||
| FaxNumber: | 3145778019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143170600 | ||||||||
| FaxNumber: | 3143170606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008022989 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2008022989 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1386865822 | 05 | MO | MEDICAID |