Basic Information
| Provider Information | |||||||||
| NPI: | 1386661916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDT | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | MSC 8238-43-1150 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627388 | ||||||||
| FaxNumber: | 3143670225 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | DIV SURG PLASTICS, STE 6G | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627388 | ||||||||
| FaxNumber: | 3143670225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0105X | R2P77 | MO | N | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 2086S0127X | R2P77 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0122X | R2P77 | MO | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 203002605 | 05 | MO | MEDICAID |