MEDICARE: DR. DAVID EDWARD BEREDA D.O.

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	207Q00000X	Family Medicine Physician	036149289	IL
2	207Q00000X	Family Medicine Physician	828	NE
3	207Q00000X	Family Medicine Physician	2022045941	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2022045941	OTHER	MO	FAMILY MEDICINE

General Provider Information

NPI Number	:	1639319387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID EDWARD BEREDA D.O.

Provider Business Mailing Address
First Line	:	1512 N GREEN MOUNT RD
Second Line	:
City	:	O FALLON
State	:	IL
Zip	:	62269-2083
Country	:	US
Telephone Number	:	618-624-5510
Fax Number	:

Provider Business Practice Location Address
First Line	:	1034 S BRENTWOOD BLVD STE 530
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-1271
Country	:	US
Telephone Number	:	314-834-6707
Fax Number	:

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

Provider Enumeration Date	:	02/20/2009
Last Update Date	:	02/02/2023

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