MEDICARE: JONATHAN D. DEHNER 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	2085R0202X	Diagnostic Radiology Physician	R5411	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1600006	OTHER	MO	MEDICARE COMPLETE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	194361	OTHER	MO	BLUE CROSS BLUE SHIELD
3	27716	OTHER	MO	GROUP HEALTH PLAN
4	3848	OTHER	MO	CMR

General Provider Information

NPI Number	:	1578581823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN D. DEHNER M.D.

Provider Business Mailing Address
First Line	:	2344 HAMPTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63139-2909
Country	:	US
Telephone Number	:	314-647-2344
Fax Number	:	314-647-5108

Provider Business Practice Location Address
First Line	:	1034 S BRENTWOOD BLVD
Second Line	:	STE 280
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-1223
Country	:	US
Telephone Number	:	314-727-0012
Fax Number	:	314-727-0014

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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Directions to “ JONATHAN D. DEHNER M.D.” Practice Location

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