Basic Information
| Provider Information | |||||||||
| NPI: | 1922366632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BELIKOFF | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 MONTVALE DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627044290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177268096 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 510 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143627200 | ||||||||
| FaxNumber: | 3147474189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 2017013059 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1922366632 | 05 | MO | MEDICAID | 1922366632 | 05 | IL | MEDICAID |