Provider Demographics
NPI:1346342920
Name:LIBRACH, STANLEY L (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:L
Last Name:LIBRACH
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 1:16216 BAXTER RD
Mailing Address - Street 2:STE 325
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-4771
Mailing Address - Country:US
Mailing Address - Phone:314-699-4013
Mailing Address - Fax:314-699-4014
Practice Address - Street 1:16216 BAXTER RD
Practice Address - Street 2:STE 325
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4771
Practice Address - Country:US
Practice Address - Phone:314-699-4013
Practice Address - Fax:314-699-4014
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105827208VP0014X, 208200000X, 204E00000X, 2082S0105X, 2084A0401X, 2086S0122X
MO0148051223G0001X, 1223S0112X
IL036086950208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036086950Medicaid
MO206971236Medicaid
IL08232029OtherBLUE SHIELD
MO122497OtherBLUE SHIELD
MO122497OtherBLUE SHIELD
IL918430Medicare ID - Type Unspecified
IL08232029OtherBLUE SHIELD
240007265Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE