Provider Demographics
NPI:1912441031
Name:HOAG, EILEEN (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:HOAG
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3867
Mailing Address - Country:US
Mailing Address - Phone:618-444-3030
Mailing Address - Fax:
Practice Address - Street 1:105 S MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3867
Practice Address - Country:US
Practice Address - Phone:618-444-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.002052133V00000X
MO2004029842133V00000X
TN1820133V00000X
NCL004676133V00000X
SC1399133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered