Healthcare Provider Details

I. General information

NPI: 1659355303
Provider Name (Legal Business Name): BRUCE SHEADE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 1ST CAPITOL DR
SAINT CHARLES MO
63301-2844
US

IV. Provider business mailing address

13523 BARRETT PARKWAY DR SUITE 210
BALLWIN MO
63021-3802
US

V. Phone/Fax

Practice location:
  • Phone: 314-989-3000
  • Fax:
Mailing address:
  • Phone: 314-775-2816
  • Fax: 314-775-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number102741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: