Healthcare Provider Details

I. General information

NPI: 1114542404
Provider Name (Legal Business Name): MICHAEL J HOHM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

IV. Provider business mailing address

670 PIERCE BLVD
O FALLON IL
62269-2579
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-2094
  • Fax: 618-607-5127
Mailing address:
  • Phone: 618-206-2094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007703
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: