Healthcare Provider Details

I. General information

NPI: 1740211986
Provider Name (Legal Business Name): MARY E BERTRAND MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 04/15/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV NEUROLOGY PEDIATRICS, STE 2130
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6120
  • Fax: 314-454-4225
Mailing address:
  • Phone: 314-454-6120
  • Fax: 314-454-4225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number103319
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number103319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: