Healthcare Provider Details

I. General information

NPI: 1558757245
Provider Name (Legal Business Name): BRENT BOWEN PICKRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E CESAR E CHAVEZ AVE STE 2200
LOS ANGELES CA
90033-2476
US

IV. Provider business mailing address

BWH 75 FRANCIS STREET
BOSTON MA
02115
US

V. Phone/Fax

Practice location:
  • Phone: 323-264-7600
  • Fax: 323-261-8027
Mailing address:
  • Phone: 617-732-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberA176983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: