Individual
JEREMY PHILLIPPE BROADNAX
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
12700 SOUTHFORK RD STE 155, SAINT LOUIS, MO 63128-3276
(314) 525-7780
(314) 525-7795
Mailing address
12700 SOUTHFORK RD STE 155, SAINT LOUIS, MO 63128-3276
(314) 525-7780
(314) 525-7795
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
2013031744
MO
207LP2900X
Pain Medicine (Anesthesiology) Physician
Primary
2013031744
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1326204611
—
MO
05
—
200332001
—
AR
01
—
431560263
TRICARE
MO
01
—
P01246688
RR MCR
MO
Enumeration date
08/06/2008
Last updated
12/08/2025
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