Healthcare Provider Details

I. General information

NPI: 1285613885
Provider Name (Legal Business Name): KEVIN B IMHOF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 HOSPITAL DR
HANNIBAL MO
63401-6890
US

IV. Provider business mailing address

6500 HOSPITAL DR P.O. BOX 1239
HANNIBAL MO
63401-6890
US

V. Phone/Fax

Practice location:
  • Phone: 573-629-3301
  • Fax: 573-629-3336
Mailing address:
  • Phone: 573-629-3301
  • Fax: 573-629-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberR2F68
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: