Healthcare Provider Details

I. General information

NPI: 1043290588
Provider Name (Legal Business Name): KORGI V HEGDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 S BIG BEND BLVD SUITE 3
SAINT LOUIS MO
63143-2112
US

IV. Provider business mailing address

PO BOX 797043
SAINT LOUIS MO
63177-7043
US

V. Phone/Fax

Practice location:
  • Phone: 314-645-5855
  • Fax: 314-645-6446
Mailing address:
  • Phone: 314-645-5855
  • Fax: 314-645-6446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberR7446
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: