Healthcare Provider Details

I. General information

NPI: 1477181980
Provider Name (Legal Business Name): CHARLES ALAN HURTH IV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9556 MANCHESTER RD
SAINT LOUIS MO
63119-1313
US

IV. Provider business mailing address

9556 MANCHESTER RD
SAINT LOUIS MO
63119-1313
US

V. Phone/Fax

Practice location:
  • Phone: 373-574-0314
  • Fax:
Mailing address:
  • Phone: 314-373-5740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023033231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: