Healthcare Provider Details

I. General information

NPI: 1437314812
Provider Name (Legal Business Name): RAYMOND ANGELO BRICKHOUSE JR. D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 S JEFFERSON AVE STE 201
SAINT LOUIS MO
63118-3922
US

IV. Provider business mailing address

PO BOX 790
EDWARDSVILLE IL
62025-0790
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-2061
  • Fax: 866-927-4145
Mailing address:
  • Phone: 267-258-7344
  • Fax: 866-927-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103300984
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005384
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2008026233
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: