Provider Demographics
NPI:1447332945
Name:HOERSCHGEN, ETHAN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:THOMAS
Last Name:HOERSCHGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 S NATIONAL AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2213
Mailing Address - Country:US
Mailing Address - Phone:417-886-5000
Mailing Address - Fax:417-886-1100
Practice Address - Street 1:1911 S NATIONAL AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2213
Practice Address - Country:US
Practice Address - Phone:417-886-5000
Practice Address - Fax:417-886-1100
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014110207R00000X
MO2007018015207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1447332945Medicaid
MO1447332945Medicare NSC
MO1447332945Medicare PIN
MO1447332945Medicare UPIN