Provider Demographics
NPI:1457355372
Name:BREITE, WARREN M (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:M
Last Name:BREITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W
Other - Middle Name:MARK
Other - Last Name:BREITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1390 HIGHWAY 61 STE 2300
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4121
Mailing Address - Country:US
Mailing Address - Phone:636-937-3121
Mailing Address - Fax:636-937-4423
Practice Address - Street 1:1390 HIGHWAY 61
Practice Address - Street 2:SUITE 2300
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4137
Practice Address - Country:US
Practice Address - Phone:636-937-3121
Practice Address - Fax:636-937-4423
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106261207RP1001X
TXG9264207RC0200X
IN01038424A207RP1001X
GA075585207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207728601Medicaid
MO110093731OtherMEDICARE RAILROAD