Basic Information
| Provider Information | |||||||||
| NPI: | 1417339383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEPBURN | ||||||||
| FirstName: | MADIHAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738821515 | ||||||||
| FaxNumber: | 5738840070 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738821515 | ||||||||
| FaxNumber: | 5738840070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 06/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2015020124 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2015020124 | 01 | MO | MISSOURI TEMPORARY LICENSE | OTHER |