Provider Demographics
NPI:1053303636
Name:BUSSMANN, CARL E (M,D)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:E
Last Name:BUSSMANN
Suffix:
Gender:M
Credentials:M,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 CONWAY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5803
Mailing Address - Country:US
Mailing Address - Phone:314-878-3571
Mailing Address - Fax:314-439-9593
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:DEPARTMENT OF EMS
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-653-5663
Practice Address - Fax:314-653-4164
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7913207PE0004X, 2086S0127X, 2086S0129X, 207P00000X
IL036117250207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201656410Medicaid
MO201656410Medicaid
MO459614748Medicare PIN
MO201656410Medicaid
ILK35258Medicare PIN
IL201656410Medicaid
A11200Medicare UPIN