MEDICARE: DR. BRUCE JAY BERWALD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	114332	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376647644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE JAY BERWALD MD

Provider Business Mailing Address
First Line	:	3478 BRIDGELAND DR
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2639
Country	:	US
Telephone Number	:	314-739-8200
Fax Number	:	314-735-4490

Provider Business Practice Location Address
First Line	:	3478 BRIDGELAND DR
Second Line	:
City	:	BRIDGETON
State	:	MO
Zip	:	63044-2619
Country	:	US
Telephone Number	:	314-739-8200
Fax Number	:	314-739-8261

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2006
Last Update Date	:	01/15/2019

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