Provider Demographics
NPI:1568568897
Name:FAN, BAOLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BAOLIN
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2331 HAMPTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-2908
Mailing Address - Country:US
Mailing Address - Phone:314-772-1441
Mailing Address - Fax:314-772-0600
Practice Address - Street 1:2331 HAMPTON AVENUE
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-2908
Practice Address - Country:US
Practice Address - Phone:314-772-1441
Practice Address - Fax:314-772-0600
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO110986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO126161Medicare UPIN