Healthcare Provider Details

I. General information

NPI: 1669102356
Provider Name (Legal Business Name): BIRUK A BEYENE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4108
US

IV. Provider business mailing address

60 BRIGHTON PARK DR
SAINT CHARLES MO
63303-3052
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-5337
  • Fax:
Mailing address:
  • Phone: 320-493-8939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME175945
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025028758
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: