Provider Demographics
NPI:1417375791
Name:HARTOG, REBECCA ROELOFS (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ROELOFS
Last Name:HARTOG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6095
Mailing Address - Fax:314-454-2561
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED CARDIOLOGY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6095
Practice Address - Fax:314-454-2561
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021018955207R00000X, 207RA0002X, 2080P0202X, 207RC0000X, 208000000X
MI43011143522080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0002XAllopathic & Osteopathic PhysiciansInternal MedicineAdult Congenital Heart Disease
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200096352Medicaid