MEDICARE: BRYON J WITZEL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2006034878	MO
2	207P00000X	Emergency Medicine Physician	085-002185	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00174465	OTHER	IL	MEDICARE RAILROAD
2	P00651238	OTHER	MO	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1528065844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYON J WITZEL PA-C

Provider Business Mailing Address
First Line	:	621 S NEW BALLAS RD
Second Line	:	SUITE 3005B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-7070
Fax Number	:	314-251-7071

Provider Business Practice Location Address
First Line	:	621 S NEW BALLAS RD
Second Line	:	SUITE 3005B
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8232
Country	:	US
Telephone Number	:	314-251-7070
Fax Number	:	314-251-7071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	03/03/2015

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Directions to “ BRYON J WITZEL PA-C” Practice Location

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