Healthcare Provider Details

I. General information

NPI: 1033485156
Provider Name (Legal Business Name): BRADLEY WILLIAM PETKOVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-3557
  • Fax:
Mailing address:
  • Phone: 314-768-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2025038953
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025038953
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number2025038953
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: