Healthcare Provider Details

I. General information

NPI: 1891747697
Provider Name (Legal Business Name): PETER BRUCE MANNING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8234
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1196
  • Fax: 314-747-3977
Mailing address:
  • Phone: 314-362-1196
  • Fax: 314-747-3977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2012037425
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number2012037425
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number2012037425
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: