Healthcare Provider Details

I. General information

NPI: 1609887983
Provider Name (Legal Business Name): BRADLEY A BECKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4014
  • Fax: 314-268-2712
Mailing address:
  • Phone: 314-268-4104
  • Fax: 314-268-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number106905
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number106905
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080I0007X
TaxonomyPediatric Clinical & Laboratory Immunology Physician
License Number106905
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number106905
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: