Healthcare Provider Details

I. General information

NPI: 1548345838
Provider Name (Legal Business Name): BERWALD SURGICAL MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3478 BRIDGELAND DR STE 2
BRIDGETON MO
63044-2619
US

IV. Provider business mailing address

3478 BRIDGELAND DR STE 2
BRIDGETON MO
63044-2619
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number114322
License Number StateMO

VIII. Authorized Official

Name: BRUCE BERWALD
Title or Position: OWNER
Credential: MD
Phone: 314-739-8200