Healthcare Provider Details

I. General information

NPI: 1235251968
Provider Name (Legal Business Name): MARY E HOHENBERG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3691 RUTGER ST
SAINT LOUIS MO
63110-2515
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6828
  • Fax:
Mailing address:
  • Phone: 314-268-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number117183
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: