Provider Demographics
NPI:1790891075
Name:MEDICAL WEST PODIATRY LTD MEDICAL WEST BLDG
Entity Type:Organization
Organization Name:MEDICAL WEST PODIATRY LTD MEDICAL WEST BLDG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BRANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-726-2377
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-726-2377
Mailing Address - Fax:314-726-2397
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:SUITE 2
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-726-2377
Practice Address - Fax:314-726-2397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790891075OtherDMERC
MO=========OtherFIN
MO990001444Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER N
MO0274780001Medicare NSC