Healthcare Provider Details

I. General information

NPI: 1982088571
Provider Name (Legal Business Name): DR. MAXWELL TANYI FOHTUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 W PINE BLVD
SAINT LOUIS MO
63108
US

IV. Provider business mailing address

4949 W PINE BLVD
SAINT LOUIS MO
63108-1431
US

V. Phone/Fax

Practice location:
  • Phone: 314-389-1496
  • Fax:
Mailing address:
  • Phone: 314-362-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2018011353
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2018011353
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDR.0069226
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: