Healthcare Provider Details

I. General information

NPI: 1821004987
Provider Name (Legal Business Name): PAUL P BUSSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN ROAD
ST LOUIS MO
63136
US

IV. Provider business mailing address

1715 DEER TRACKS TRAIL STE 130
ST LOUIS MO
63131
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-4300
  • Fax: 314-821-2180
Mailing address:
  • Phone: 314-821-5600
  • Fax: 314-821-2180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number34803
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: