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General NPI Number Information
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NPI Number | 1326204611
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Entity Type | Individual
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Provider Name | JEREMY PHILLIPPE BROADNAX M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/06/2008
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 12700 SOUTHFORK RD STE 155
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City | SAINT LOUIS
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State | MO
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Zip | 63128-3276
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Country | US
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Telephone | 314-525-7780
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Fax | 314-525-7795
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Provider Business Mailing Address
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Address Line | 12700 SOUTHFORK RD STE 155
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City | SAINT LOUIS
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State | MO
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Zip | 63128-3276
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Country | US
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Telephone | 314-525-7780
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Fax | 314-525-7795
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 2013031744
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 2013031744
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License Number State | MO
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