Healthcare Provider Details

I. General information

NPI: 1497890867
Provider Name (Legal Business Name): MICHAEL W MAHONEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W 6TH ST
HERMANN MO
65041-1018
US

IV. Provider business mailing address

PO BOX 19
HERMANN MO
65041-0019
US

V. Phone/Fax

Practice location:
  • Phone: 573-486-5711
  • Fax: 573-486-3827
Mailing address:
  • Phone: 573-486-1193
  • Fax: 573-486-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR6775
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: