Healthcare Provider Details

I. General information

NPI: 1770513319
Provider Name (Legal Business Name): BRENT T ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/15/2025
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N NEW BALLAS RD DIV SURG VASCULAR, STE 265
SAINT LOUIS MO
63141-6825
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-4644
  • Fax: 866-342-0133
Mailing address:
  • Phone: 314-991-4644
  • Fax: 866-342-0133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR2B05
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: