Healthcare Provider Details

I. General information

NPI: 1750375812
Provider Name (Legal Business Name): BRIAN BERGFELD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7419 WATSON RD
SAINT LOUIS MO
63119-4415
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-400-3360
  • Fax: 314-400-3361
Mailing address:
  • Phone: 314-400-3360
  • Fax: 314-400-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004015369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: