Healthcare Provider Details

I. General information

NPI: 1205327111
Provider Name (Legal Business Name): BRANDON MICHAEL WUBBEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 09/09/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PROGRESS POINT PKWY DEPT EMERGENCY MED
O FALLON MO
63368-2205
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax: 314-747-9160
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2025029102
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: