Healthcare Provider Details

I. General information

NPI: 1053303636
Provider Name (Legal Business Name): CARL E. BUSSMANN M,D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD DEPARTMENT OF EMS
SAINT LOUIS MO
63136-6119
US

IV. Provider business mailing address

409 CONWAY VILLAGE DR
SAINT LOUIS MO
63141-5803
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5663
  • Fax: 314-653-4164
Mailing address:
  • Phone: 314-878-3571
  • Fax: 314-439-9593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberR7913
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberR7913
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR7913
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR7913
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036117250
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: