Healthcare Provider Details

I. General information

NPI: 1285344903
Provider Name (Legal Business Name): BRETT GREGORY BEUTENMILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/05/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4483 DUNCAN AVE
SAINT LOUIS MO
63110-1111
US

IV. Provider business mailing address

6251 NOTTINGHAM AVE APT 2E
SAINT LOUIS MO
63109-3162
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-7055
  • Fax:
Mailing address:
  • Phone: 573-289-3901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2013026822
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: