Healthcare Provider Details

I. General information

NPI: 1912211343
Provider Name (Legal Business Name): JOHN HEARN MD, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD DEPT OF
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

1438 S GRAND BLVD DEPT OF
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-2462
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number2011034013
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2011034013
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: