Healthcare Provider Details

I. General information

NPI: 1881613347
Provider Name (Legal Business Name): KENNETH R BRIGHTFIELD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR SUITE 280
ST. LOUIS MO
63141
US

V. Phone/Fax

Practice location:
  • Phone: 314-432-4415
  • Fax: 314-432-1986
Mailing address:
  • Phone: 314-432-4415
  • Fax: 314-432-1986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR5C32
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: