MEDICARE: STEPHAN BRENNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	2006014091	MO

General Provider Information

NPI Number	:	1306019914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHAN BRENNER MD

Provider Business Mailing Address
First Line	:	4628 MCPHERSON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1937
Country	:	US
Telephone Number	:	312-208-7304
Fax Number	:

Provider Business Practice Location Address
First Line	:	4628 MCPHERSON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1937
Country	:	US
Telephone Number	:	312-208-7304
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	04/04/2008

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