Healthcare Provider Details

I. General information

NPI: 1215098983
Provider Name (Legal Business Name): BRENTWOOD PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S BRENTWOOD BLVD STE 100
SAINT LOUIS MO
63144-1301
US

IV. Provider business mailing address

1600 S BRENTWOOD BLVD STE 100
SAINT LOUIS MO
63144-1301
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: DR. JEAN BIRMINGHAM
Title or Position: OWNER PHYSICIAN
Credential: MD
Phone: 314-918-8827