Provider Demographics
NPI:1326023185
Name:WANNER-BARJENBRUCH, PEGGY (MD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:WANNER-BARJENBRUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3724
Mailing Address - Country:US
Mailing Address - Phone:573-581-1040
Mailing Address - Fax:573-581-5397
Practice Address - Street 1:600 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3724
Practice Address - Country:US
Practice Address - Phone:573-581-8500
Practice Address - Fax:573-581-5397
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F18207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202222303Medicaid
001011808Medicare ID - Type Unspecified
E09326Medicare UPIN