Healthcare Provider Details

I. General information

NPI: 1205332194
Provider Name (Legal Business Name): VICKY HWANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2018
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E HIGHWAY 50
O FALLON IL
62269-2704
US

IV. Provider business mailing address

320 E HIGHWAY 50
O FALLON IL
62269-2704
US

V. Phone/Fax

Practice location:
  • Phone: 618-624-3368
  • Fax:
Mailing address:
  • Phone: 618-624-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.155319
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036155319
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: