Basic Information
| Provider Information | |||||||||
| NPI: | 1699783563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEUSCHWANDER-TETRI | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | TETRI | ||||||||
| OtherFirstName: | BRENT | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1008 S SPRING AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149772140 | ||||||||
| FaxNumber: | 3149771660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 S GRAND BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631041016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142573760 | ||||||||
| FaxNumber: | 3142573761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | R3P51 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 203018007 | 05 | MO | MEDICAID |