Healthcare Provider Details

I. General information

NPI: 1780244731
Provider Name (Legal Business Name): MATTHEW HOBART MARDIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

DEPARTMENT OF ANESTHESIOLOGY 1 HOSPITAL DRIVE
COLUMBIA MO
65212-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5956
  • Fax: 859-323-1080
Mailing address:
  • Phone: 573-882-9522
  • Fax: 573-882-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2019021882
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTP594
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number58082
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: