Healthcare Provider Details

I. General information

NPI: 1659868040
Provider Name (Legal Business Name): WILLIAM LOUIS HOLLABAUGH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/17/2025
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROGRESS POINT PKWY DEPT ORTHOPAEDIC SURGERY, STE 114
O FALLON MO
63368-2206
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-514-3500
  • Fax: 314-878-7678
Mailing address:
  • Phone: 314-514-3500
  • Fax: 314-878-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number2024016238
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: