Provider Demographics
NPI:1851463756
Name:BIEDERMANN, GREGORY B (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:B
Last Name:BIEDERMANN
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 1:1705 E BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7166
Mailing Address - Country:US
Mailing Address - Phone:573-874-7800
Mailing Address - Fax:573-443-3627
Practice Address - Street 1:1705 E BROADWAY
Practice Address - Street 2:STE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7166
Practice Address - Country:US
Practice Address - Phone:573-874-7800
Practice Address - Fax:573-443-3627
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240320207R00000X
MO20090103382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1851463756Medicaid
VA0101240320OtherMEDICAL LICENSE
MO127000001Medicare PIN
MOP00745714Medicare PIN
VA0101240320OtherMEDICAL LICENSE
MO127530007Medicare PIN
000092300Medicare ID - Type Unspecified
MO1851463756Medicaid