Provider Demographics
NPI:1194796698
Name:HATLELID, JOHN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:HATLELID
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 1:3009 N BALLAS RD STE 102B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2343
Mailing Address - Country:US
Mailing Address - Phone:314-996-7080
Mailing Address - Fax:
Practice Address - Street 1:3009 N BALLAS RD STE 102B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2343
Practice Address - Country:US
Practice Address - Phone:314-996-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR86152084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO130001273OtherRAILROAD MEDICARE
ILL56693Medicare PIN
MO001012262Medicare PIN
MOA10006Medicare UPIN