Provider Demographics
NPI:1497736979
Name:CITY OF BRENTWOOD
Entity Type:Organization
Organization Name:CITY OF BRENTWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LT./MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:STOVERINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-963-8612
Mailing Address - Street 1:PO BOX 798126
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-8000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2348 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MO
Practice Address - Zip Code:63144-2034
Practice Address - Country:US
Practice Address - Phone:314-963-8612
Practice Address - Fax:314-963-3869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1890903416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
30341OtherGHP PROVIDER NO.
21894OtherHEALTHCAREUSA PROV. NO.
590012547OtherRAILROAD MEDICARE PROV. #
8181900OtherUNITED HEALTHCARE PROV NO
389227OtherHEALTHLINK
128050OtherBCBS PROVIDER NO.
MO809739006Medicaid
21894OtherHEALTHCAREUSA PROV. NO.