Provider Demographics
NPI:1376647644
Name:BERWALD, BRUCE JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JAY
Last Name:BERWALD
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 1:3478 BRIDGELAND DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2639
Mailing Address - Country:US
Mailing Address - Phone:314-739-8200
Mailing Address - Fax:314-735-4490
Practice Address - Street 1:3478 BRIDGELAND DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2619
Practice Address - Country:US
Practice Address - Phone:314-739-8200
Practice Address - Fax:314-739-8261
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205292204Medicaid
G76197Medicare UPIN
MO205292204Medicaid