Provider Demographics
NPI:1992797963
Name:HORNBOSTEL, PHILLIP M (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:M
Last Name:HORNBOSTEL
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 1:802 N RIVERSIDE RD STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2509
Mailing Address - Country:US
Mailing Address - Phone:816-271-6155
Mailing Address - Fax:660-827-5510
Practice Address - Street 1:802 N RIVERSIDE RD STE 220
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2509
Practice Address - Country:US
Practice Address - Phone:816-271-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9A37208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201412020Medicaid
MOC184858Medicare ID - Type Unspecified
MO201412020Medicaid