Provider Demographics
NPI:1740776251
Name:CHRISTINA H DOTHAGER MD LLC
Entity Type:Organization
Organization Name:CHRISTINA H DOTHAGER MD LLC
Other - Org Name:SERENE WOMEN'S WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HATHAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-292-4887
Mailing Address - Street 1:787 SUNSET BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1960
Mailing Address - Country:US
Mailing Address - Phone:618-726-2229
Mailing Address - Fax:
Practice Address - Street 1:787 SUNSET BLVD STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1960
Practice Address - Country:US
Practice Address - Phone:618-726-2229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-09
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-125618Medicaid