Provider Demographics
NPI:1548345838
Name:BERWALD SURGICAL MEDICAL INC
Entity type:Organization
Organization Name:BERWALD SURGICAL MEDICAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-739-8200
Mailing Address - Street 1:3478 BRIDGELAND DR
Mailing Address - Street 2:STE 2
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3478 BRIDGELAND DR
Practice Address - Street 2:STE 2
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2619
Practice Address - Country:US
Practice Address - Phone:314-739-8200
Practice Address - Fax:314-739-8261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114322332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
2635653OtherOTHER ID NUMBER-COMMERCIAL NUMBER