MEDICARE: RALPH ROBERT HATLELID M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	R3B09	MO

General Provider Information

NPI Number	:	1184056830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RALPH ROBERT HATLELID M.D.

Provider Business Mailing Address
First Line	:	318 E SWON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-3112
Country	:	US
Telephone Number	:	314-395-1876
Fax Number	:	314-395-1876

Provider Business Practice Location Address
First Line	:	318 E SWON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63119-3112
Country	:	US
Telephone Number	:	314-395-1876
Fax Number	:	314-395-1876

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2013
Last Update Date	:	08/05/2013

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