Healthcare Provider Details

I. General information

NPI: 1760772966
Provider Name (Legal Business Name): KENNETH EDMOND HEMBA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2011
Last Update Date: 01/18/2022
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

IV. Provider business mailing address

4352 MANCHESTER AVE
SAINT LOUIS MO
63110-2138
US

V. Phone/Fax

Practice location:
  • Phone: 314-531-5444
  • Fax: 314-531-0063
Mailing address:
  • Phone: 314-531-5444
  • Fax: 314-531-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014010092
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: