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General NPI Number Information
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NPI Number | 1033485156
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Entity Type | Individual
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Provider Name | BRADLEY WILLIAM PETKOVICH M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2012
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 6420 CLAYTON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63117-1811
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Country | US
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Telephone | 314-617-3557
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Fax |
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Provider Business Mailing Address
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Address Line | 1008 S SPRING AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63110-2520
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Country | US
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Telephone | 314-768-8622
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 2025038953
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2025038953
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 207RC0200X
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Taxonomy Name | Critical Care Medicine (Internal Medicine) Physician
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License Number | 2025038953
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License Number State | MO
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