Healthcare Provider Details

I. General information

NPI: 1699977686
Provider Name (Legal Business Name): BRENT K. HABERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-6413
  • Fax: 314-268-6412
Mailing address:
  • Phone: 314-268-6439
  • Fax: 314-268-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016042899
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number2016042899
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number47526
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License Number2016042899
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: