Provider Demographics
NPI:1326204611
Name:BROADNAX, JEREMY PHILLIPPE (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:PHILLIPPE
Last Name:BROADNAX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD STE 155
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3276
Mailing Address - Country:US
Mailing Address - Phone:314-525-7780
Mailing Address - Fax:314-525-7795
Practice Address - Street 1:12700 SOUTHFORK RD STE 155
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3276
Practice Address - Country:US
Practice Address - Phone:314-525-7780
Practice Address - Fax:314-525-7795
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2025-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013031744207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200332001Medicaid
MO431560263OtherTRICARE
MO1326204611Medicaid
MOP01246688OtherRR MCR
MO1326204611Medicaid
MOP01246688OtherRR MCR