Provider Demographics
NPI:1437314812
Name:BRICKHOUSE, RAYMOND ANGELO JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:ANGELO
Last Name:BRICKHOUSE
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0790
Mailing Address - Country:US
Mailing Address - Phone:267-258-7344
Mailing Address - Fax:866-927-4145
Practice Address - Street 1:3535 S JEFFERSON AVE STE 201
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3922
Practice Address - Country:US
Practice Address - Phone:314-567-2061
Practice Address - Fax:866-927-4145
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300984213ES0103X
IL016005384213ES0103X
MO2008026233213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1437314812Medicaid
ILIL2191Medicare PIN
MO6342080001Medicare NSC
MOMA1359Medicare PIN