MEDICARE: BRYCE DECIDUE STASH M.D.

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	208200000X	Plastic Surgery Physician	2016019983	MO

General Provider Information

NPI Number	:	1972954345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYCE DECIDUE STASH M.D.

Provider Business Mailing Address
First Line	:	1720 CHOUTEAU AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-3112
Country	:	US
Telephone Number	:	325-660-4747
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 CHOUTEAU AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-3112
Country	:	US
Telephone Number	:	325-660-4747
Fax Number	:

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

Provider Enumeration Date	:	06/28/2016
Last Update Date	:	06/28/2016

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