Basic Information
| Provider Information | |||||||||
| NPI: | 1417339375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HANNON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8233 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145143500 | ||||||||
| FaxNumber: | 3145143555 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | STE 6A/6B/12A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147472551 | ||||||||
| FaxNumber: | 3147472598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2021017680 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 2021017680 | MO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200099727 | 05 | MO | MEDICAID |