Healthcare Provider Details

I. General information

NPI: 1184056830
Provider Name (Legal Business Name): RALPH ROBERT HATLELID M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E SWON AVE
SAINT LOUIS MO
63119-3112
US

IV. Provider business mailing address

318 E SWON AVE
SAINT LOUIS MO
63119-3112
US

V. Phone/Fax

Practice location:
  • Phone: 314-395-1876
  • Fax: 314-395-1876
Mailing address:
  • Phone: 314-395-1876
  • Fax: 314-395-1876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR3B09
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: