Healthcare Provider Details

I. General information

NPI: 1376647644
Provider Name (Legal Business Name): BRUCE JAY BERWALD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3478 BRIDGELAND DR
BRIDGETON MO
63044-2619
US

IV. Provider business mailing address

3478 BRIDGELAND DR
BRIDGETON MO
63044-2639
US

V. Phone/Fax

Practice location:
  • Phone: 314-739-8200
  • Fax: 314-739-8261
Mailing address:
  • Phone: 314-739-8200
  • Fax: 314-735-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number114332
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: