Provider Demographics
NPI:1558313148
Name:FOGEL, STEVEN TEDD (MD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:TEDD
Last Name:FOGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 THORNBROOK RDG
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9750
Mailing Address - Country:US
Mailing Address - Phone:157-335-5142
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2569
Practice Address - Fax:573-882-2226
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8071207L00000X
GA056442207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA629589513AMedicaid
MO201302338Medicaid
MO958490635Medicare PIN
GA05BDKSFMedicare ID - Type Unspecified
GA629589513AMedicaid
MO958495236Medicare PIN
MO201302338Medicaid
MOP00332524Medicare PIN
MOP00427286Medicare PIN