Basic Information
| Provider Information | |||||||||
| NPI: | 1215986435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANTRUP | ||||||||
| FirstName: | GREGG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13523 BARRETT PARKWAY DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630213802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147752816 | ||||||||
| FaxNumber: | 3147752821 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 1ST CAPITOL DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149893000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2006 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 108695 | MO | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | P00139813 | 01 | MO | RR MEDICARE | OTHER | 208042010 | 05 | MO | MEDICAID |