Healthcare Provider Details

I. General information

NPI: 1659428050
Provider Name (Legal Business Name): KIRK E. BROCKMAN M.D. DBA ST. CLAIR MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 N COMMERCIAL AVE
SAINT CLAIR MO
63077-1305
US

IV. Provider business mailing address

370 N COMMERCIAL AVE
SAINT CLAIR MO
63077-1305
US

V. Phone/Fax

Practice location:
  • Phone: 636-629-3300
  • Fax: 636-629-7377
Mailing address:
  • Phone: 636-629-3300
  • Fax: 636-629-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR2F53
License Number StateMO

VIII. Authorized Official

Name: DR. KIRK EDWARD BROCKMAN
Title or Position: OWNER
Credential: M.D.
Phone: 636-629-3300