Healthcare Provider Details

I. General information

NPI: 1053516294
Provider Name (Legal Business Name): BARRY MICHAEL MOSSMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 390C
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

2 MEMORIAL DR STE 220
ALTON IL
62002-6723
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-5900
  • Fax:
Mailing address:
  • Phone: 618-474-1723
  • Fax: 618-474-6988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036-120094
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: