Provider Demographics
NPI:1942225305
Name:BRUCKEL, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BRUCKEL
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 1:9556 MANCHESTER ROAD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1313
Mailing Address - Country:US
Mailing Address - Phone:314-961-2255
Mailing Address - Fax:314-373-5757
Practice Address - Street 1:9556 MANCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1313
Practice Address - Country:US
Practice Address - Phone:314-961-2255
Practice Address - Fax:314-373-5757
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005029371207P00000X
FLME85875207P00000X
GA051440207P00000X
PAMD071774L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200520005Medicaid
MO200520005Medicaid
MO200520005Medicaid
MO939714740Medicare PIN
MO939703209Medicare PIN
MO939704748Medicare PIN
IL$$$$$$$$$Medicaid