Provider Demographics
NPI:1427165935
Name:BASKIR, BRUCE MATATHIAS (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:MATATHIAS
Last Name:BASKIR
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 1:3165 MCKELVEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2550
Mailing Address - Country:US
Mailing Address - Phone:314-739-1333
Mailing Address - Fax:314-739-1350
Practice Address - Street 1:3165 MCKELVEY RD STE 100
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-739-1333
Practice Address - Fax:314-739-1350
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6G51174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207930934Medicaid
MOE77221Medicare UPIN
MO207930934Medicaid