Healthcare Provider Details

I. General information

NPI: 1063475523
Provider Name (Legal Business Name): JEAN E BIRMINGHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S BRENTWOOD BLVD SUITE 100
SAINT LOUIS MO
63144-1320
US

IV. Provider business mailing address

1600 S BRENTWOOD BLVD SUITE 100
SAINT LOUIS MO
63144-1320
US

V. Phone/Fax

Practice location:
  • Phone: 314-918-8827
  • Fax: 314-918-9391
Mailing address:
  • Phone: 314-918-8827
  • Fax: 314-918-9391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR1P89
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: