Provider Demographics
NPI:1003336819
Name:HODAG MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:HODAG MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:314-821-5002
Mailing Address - Street 1:1324 CLARKSON CLAYTON CTR UNIT 301
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2145
Mailing Address - Country:US
Mailing Address - Phone:314-541-6838
Mailing Address - Fax:
Practice Address - Street 1:4800 MEXICO RD STE 103
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-936-5002
Practice Address - Fax:314-821-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G71207YX0602X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242428308Medicaid
1790786838OtherNPI