Provider Demographics
NPI:1003952458
Name:BIALECKI, ELDAD SHAUL (MD)
Entity Type:Individual
Prefix:
First Name:ELDAD
Middle Name:SHAUL
Last Name:BIALECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-355-4010
Mailing Address - Fax:314-355-9484
Practice Address - Street 1:100 VILLAGE SQ
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1820
Practice Address - Country:US
Practice Address - Phone:314-355-4010
Practice Address - Fax:314-355-9484
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013331207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510094Medicare PIN
MO0010481Medicare PIN