Healthcare Provider Details

I. General information

NPI: 1316986540
Provider Name (Legal Business Name): RICHARD XAVIER BRENNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12700 SOUTHFORK RD STE 230
SAINT LOUIS MO
63128-3201
US

IV. Provider business mailing address

12700 SOUTHFORK RD STE 230
SAINT LOUIS MO
63128-3201
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-3711
  • Fax: 314-849-0235
Mailing address:
  • Phone: 314-849-3711
  • Fax: 314-849-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMDR6H23
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number336-069221
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: