Provider Demographics
NPI:1740200187
Name:BIENEMAN, BRUCE K (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:K
Last Name:BIENEMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8200
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-4492
Practice Address - Fax:314-525-4481
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2020-10-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO1088772085N0700X, 2085R0204X, 2085R0202X
IL0361019772085R0202X
IAMD-339642085R0202X
KS04-289302085R0202X
PAMD4595472085R0202X
TN351732085R0202X
VA01012409192085R0202X
WV210522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL366644640Medicaid
MO203935416Medicaid
MO203935416Medicaid
IL366644640Medicaid