Provider Demographics
NPI:1407084593
Name:KAEBNICK, BRIAN WALTER (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WALTER
Last Name:KAEBNICK
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 1:232 S WOODS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:222 S WOODS MILL RD STE 500N
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-205-6699
Practice Address - Fax:314-590-5923
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52594207RI0011X
MO2016011517207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid