Healthcare Provider Details

I. General information

NPI: 1003336819
Provider Name (Legal Business Name): HODAG MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 MEXICO RD STE 103
SAINT PETERS MO
63376-1666
US

IV. Provider business mailing address

1324 CLARKSON CLAYTON CTR UNIT 301
ELLISVILLE MO
63011-2145
US

V. Phone/Fax

Practice location:
  • Phone: 636-936-5002
  • Fax: 314-821-5029
Mailing address:
  • Phone: 314-541-6838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberR6G71
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberR6G71
License Number StateMO

VIII. Authorized Official

Name: PAUL E. BURK
Title or Position: PHYSICIAN
Credential: DO
Phone: 314-821-5002