Provider Demographics
NPI:1033160734
Name:MIEDEMA, BRENT W (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:W
Last Name:MIEDEMA
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 1:800 HOSPITAL DR # 617
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5275
Mailing Address - Country:US
Mailing Address - Phone:573-814-6346
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR # 617
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5275
Practice Address - Country:US
Practice Address - Phone:573-814-6346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR7N00208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO20021458OtherRR MEDICARE
MO203229802Medicaid
MOP00676654Medicare PIN
MO203229802Medicaid
E63811Medicare UPIN
MO20021458OtherRR MEDICARE