Provider Demographics
NPI:1235139221
Name:BROCKMAN, KIRK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:EDWARD
Last Name:BROCKMAN
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 1:1001 CARDWELL STREET
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077
Mailing Address - Country:US
Mailing Address - Phone:636-629-3300
Mailing Address - Fax:636-629-7377
Practice Address - Street 1:1001 CARDWELL ST
Practice Address - Street 2:
Practice Address - City:ST. CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077
Practice Address - Country:US
Practice Address - Phone:636-629-3300
Practice Address - Fax:636-629-7377
Is Sole Proprietor?:No
Enumeration Date:2005-07-30
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F53207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01134547OtherRAILROAD MEDICARE
MO202458204Medicaid
MO0767820001Medicare NSC
MO152810076Medicare PIN
MOA14049Medicare UPIN
MO202458204Medicaid