Provider Demographics
NPI:1659428050
Name:KIRK E. BROCKMAN M.D. DBA ST. CLAIR MEDICAL CENTER
Entity Type:Organization
Organization Name:KIRK E. BROCKMAN M.D. DBA ST. CLAIR MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-629-3300
Mailing Address - Street 1:370 N COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077-1305
Mailing Address - Country:US
Mailing Address - Phone:636-629-3300
Mailing Address - Fax:636-629-7377
Practice Address - Street 1:370 N COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1305
Practice Address - Country:US
Practice Address - Phone:636-629-3300
Practice Address - Fax:636-629-7377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F53207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500013503Medicaid
MO500013503Medicaid
MO0767820001Medicare NSC