Provider Demographics
NPI:1053515726
Name:FISSEL, BRIAN ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANTHONY
Last Name:FISSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:12639 OLD TESSON RD
Practice Address - Street 2:SUITE 115
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2786
Practice Address - Country:US
Practice Address - Phone:314-849-0311
Practice Address - Fax:314-849-4423
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009012784207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1053515726Medicaid
MO122950012Medicare PIN