Basic Information
| Provider Information | |||||||||
| NPI: | 1437314812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRICKHOUSE | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | ANGELO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.P.M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 790 | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620250790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2672587344 | ||||||||
| FaxNumber: | 8669274145 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 S JEFFERSON AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631183922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145672061 | ||||||||
| FaxNumber: | 8669274145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 05/11/2010 | ||||||||
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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 | 213ES0103X | 0103300984 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 016005384 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 2008026233 | MO | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1437314812 | 05 | MO | MEDICAID |