Provider Demographics
NPI:1952527640
Name:THAL, SANFORD MYRON (MD)
Entity Type:Individual
Prefix:
First Name:SANFORD
Middle Name:MYRON
Last Name:THAL
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 1:2040 CONCOURSE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4119
Mailing Address - Country:US
Mailing Address - Phone:314-567-3905
Mailing Address - Fax:314-872-7155
Practice Address - Street 1:2040 CONCOURSE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4119
Practice Address - Country:US
Practice Address - Phone:314-567-3905
Practice Address - Fax:314-872-7155
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36215207ZP0102X
ARE-4688207ZP0102X
UT173539-1205207ZP0102X
NE23326207ZP0102X
KS04-31574207ZP0102X
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE18503Medicare UPIN