Provider Demographics
NPI:1780137356
Name:RAYMOND A. BRICKHOUSE, DPM LLC
Entity type:Organization
Organization Name:RAYMOND A. BRICKHOUSE, DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRICKHOUSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-381-1800
Mailing Address - Street 1:6400 CLAYTON RD STE 412
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1850
Mailing Address - Country:US
Mailing Address - Phone:314-381-1800
Mailing Address - Fax:866-927-4145
Practice Address - Street 1:3535 S JEFFERSON AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-3930
Practice Address - Country:US
Practice Address - Phone:314-381-1802
Practice Address - Fax:866-927-4145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAYMOND A. BRICKHOUSE, DPM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008026233332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1437314812Medicaid
MOMA1359Medicare PIN
MO6692370002Medicare PIN
MOMA575001Medicare PIN
ILIL2191Medicare PIN
MOMA5750Medicare PIN
MO1437314812Medicaid