Provider Demographics
NPI:1467468520
Name:STROMBERG, BRENT V (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:V
Last Name:STROMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 419074
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9074
Mailing Address - Country:US
Mailing Address - Phone:314-997-8828
Mailing Address - Fax:314-432-5105
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-997-8828
Practice Address - Fax:314-432-5105
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4B42208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203062401Medicaid
MO000003585Medicare ID - Type Unspecified
MOB67994Medicare UPIN
MO240002175Medicare ID - Type UnspecifiedRAILROAD MEDICARE