Healthcare Provider Details

I. General information

NPI: 1013013093
Provider Name (Legal Business Name): THOMAS E DAHLBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 S CAMPBELL AVE STE T-1
SPRINGFIELD MO
65807-4980
US

IV. Provider business mailing address

3322 S CAMPBELL AVE STE T-1
SPRINGFIELD MO
65807-4980
US

V. Phone/Fax

Practice location:
  • Phone: 417-220-4480
  • Fax: 417-414-0017
Mailing address:
  • Phone: 417-220-4480
  • Fax: 417-900-2992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD104392
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD104392
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: