Healthcare Provider Details

I. General information

NPI: 1801423652
Provider Name (Legal Business Name): ADAM NIKOLAUS BENCKENDORF DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD # M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

4068 FEDERER ST
SAINT LOUIS MO
63116-2815
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8933
  • Fax:
Mailing address:
  • Phone: 314-894-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2024009634
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: