Basic Information
| Provider Information | |||||||||
| NPI: | 1710243233 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAHL | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 E MISSOURI AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850121351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022628900 | ||||||||
| FaxNumber: | 6022628890 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182337750 | ||||||||
| FaxNumber: | 3147475157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2012 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2017000619 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 2017000619 | MO | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200050503 | 05 | MO | MEDICAID |