Healthcare Provider Details

I. General information

NPI: 1245857036
Provider Name (Legal Business Name): SARAH MARIAH PETH BOHNERT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS SARAH MARIAH PETH

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N HOSPITAL DR
FULTON MO
65251-2511
US

IV. Provider business mailing address

110 N HOSPITAL DR
FULTON MO
65251-2511
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-5911
  • Fax: 573-642-3015
Mailing address:
  • Phone: 573-642-5911
  • Fax: 573-642-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020019023
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023009377
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: