Provider Demographics
NPI:1487670600
Name:NUSSENBAUM, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:NUSSENBAUM
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 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-7509
Mailing Address - Fax:314-747-5593
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:STE 11A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7509
Practice Address - Fax:314-747-9744
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002009369207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208731505Medicaid
MOP00064830Medicare PIN
MO052010206Medicare PIN
IL$$$$$$$$$Medicaid