Basic Information
| Provider Information | |||||||||
| NPI: | 1558313148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGEL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | TEDD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4904 THORNBROOK RDG | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652039750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1573355142 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652120001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738822569 | ||||||||
| FaxNumber: | 5738822226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | R8071 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 629589513A | 05 | GA | MEDICAID | 201302338 | 05 | MO | MEDICAID |