Healthcare Provider Details

I. General information

NPI: 1306984505
Provider Name (Legal Business Name): BRIAN L. MAHAFFEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15945 CLAYTON RD SUITE 210
BALLWIN MO
63011-2490
US

IV. Provider business mailing address

15945 CLAYTON RD SUITE 210
BALLWIN MO
63011-2490
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-1556
  • Fax: 636-893-1362
Mailing address:
  • Phone: 636-893-1360
  • Fax: 636-893-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number103424
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: