Basic Information
Provider Information | |||||||||
NPI: | 1053792325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLIGARD | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | HOLLISTER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4901 FOREST PARK AVE | ||||||||
Address2: | MSC 8064-37-1005 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631081495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3144548181 | ||||||||
FaxNumber: | 3147471429 | ||||||||
Practice Location | |||||||||
Address1: | 4901 FOREST PARK AVE | ||||||||
Address2: | DIV OBGYN MFM / ULTRASOUND, STE 710 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631081495 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3144548181 | ||||||||
FaxNumber: | 3147471429 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/12/2015 | ||||||||
LastUpdateDate: | 11/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2019005949 | MO | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 200061663 | 05 | MO |   | MEDICAID |