Basic Information
| Provider Information | |||||||||
| NPI: | 1033484175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAYMOND A. BRICKHOUSE, DPM LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 CLAYTON RD STE 412 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143811800 | ||||||||
| FaxNumber: | 3144227749 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 CLAYTON RD | ||||||||
| Address2: | SUITE 412 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143811800 | ||||||||
| FaxNumber: | 8669274145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2012 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRICKHOUSE | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | ANGELO | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3143811800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 2008026233 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1437314812 | 05 | MO | MEDICAID |