Provider Demographics
NPI:1790791861
Name:TAILOR, CHANDRAKANT C (MD)
Entity Type:Individual
Prefix:
First Name:CHANDRAKANT
Middle Name:C
Last Name:TAILOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 DEER TRACKS TRAIL
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136
Practice Address - Country:US
Practice Address - Phone:314-653-4300
Practice Address - Fax:314-821-2180
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR74522085R0202X
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
102372OtherHLINK
18485OtherBLUE CHOICE
0006021895OtherIL BLUE
2781OtherGHP
IL49523700581Medicaid
347617OtherHLT PART
1390OtherMO BLUE
1078068OtherMC MCAID
1609016OtherPH PLAN
4876OtherHCARE USA
A12405OtherGATEWAY
1078068OtherMC MCAID
1609016OtherPH PLAN
ILL40185Medicare ID - Type Unspecified
1390OtherMO BLUE