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General NPI Number Information
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NPI Number | 1073166864
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Entity Type | Individual
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Provider Name | BRYAN BENGSTON
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Gender | Male
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Dates
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Enumeration Date | 07/20/2019
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Last Update Date | 07/20/2019
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Provider Practice Location Address
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Address Line | 624 SESSIONS AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63126-1030
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Country | US
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Telephone | 314-974-0416
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Fax |
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Provider Business Mailing Address
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Address Line | 624 SESSIONS AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63126-1030
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Country | US
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Telephone | 314-974-0416
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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 | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 2009005829
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License Number State | MO
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