Provider Demographics
NPI:1275551194
Name:EGGEBRECHT, RUSSELL E (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:EGGEBRECHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-862-5044
Mailing Address - Fax:314-862-2734
Practice Address - Street 1:8888 LADUE RD
Practice Address - Street 2:STE 210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2056
Practice Address - Country:US
Practice Address - Phone:314-862-5044
Practice Address - Fax:314-862-2734
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5480207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202631628Medicaid
MO110056201OtherRR MEDICARE
MO202631628Medicaid
MO110056201OtherRR MEDICARE