Provider Demographics
NPI:1093754715
Name:CHACKO, RUTH (MD)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 LACKLAND HILL PKWY
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3572
Mailing Address - Country:US
Mailing Address - Phone:314-989-0300
Mailing Address - Fax:314-810-1399
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-768-8000
Practice Address - Fax:314-768-8011
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9305207P00000X
IL036060005207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1093754715Medicaid
IL$$$$$$$$$-3Medicaid
MO134050166Medicare ID - Type UnspecifiedSMHC-MO
MO156580037Medicare PIN