Provider Demographics
NPI:1912160805
Name:MCGILL, BRYAN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:EDWARD
Last Name:MCGILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8111
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-6042
Mailing Address - Fax:314-454-6142
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6042
Practice Address - Fax:314-454-6142
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20110092512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1912160805Medicaid