Healthcare Provider Details

I. General information

NPI: 1932365665
Provider Name (Legal Business Name): MARY VATTEROTT HASTINGS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 N HANLEY RD ST LOUIS COUNTY DEPARTMENT OF HEALTH
SAINT LOUIS MO
63134-2003
US

IV. Provider business mailing address

1402 S. GRAND DEPARTMENT OF FAMILY MEDICINE
ST LOUIS MO
63104
US

V. Phone/Fax

Practice location:
  • Phone: 314-615-5767
  • Fax: 314-615-5629
Mailing address:
  • Phone: 314-977-8492
  • Fax: 314-977-5268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR8E99
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMOR8399
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: