Healthcare Provider Details

I. General information

NPI: 1073722872
Provider Name (Legal Business Name): DOUGLAS J HEPBURN MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S KIRKWOOD RD SUITE 201
KIRKWOOD MO
63122-6161
US

IV. Provider business mailing address

833 TOWNHOUSE LN
HAZELWOOD MO
63042-3418
US

V. Phone/Fax

Practice location:
  • Phone: 314-909-0517
  • Fax: 314-909-0518
Mailing address:
  • Phone: 314-920-1255
  • Fax: 314-909-0518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2002023837
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: