Healthcare Provider Details

I. General information

NPI: 1780117085
Provider Name (Legal Business Name): MADELINE BRUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADELINE NOVOA

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

IV. Provider business mailing address

401 HOLLY HILLS AVE
SAINT LOUIS MO
63111-2410
US

V. Phone/Fax

Practice location:
  • Phone: 314-353-5190
  • Fax:
Mailing address:
  • Phone: 314-353-5190
  • Fax: 314-353-7631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2021012619
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: