Provider Demographics
NPI:1093093064
Name:PENNICOOKE, BRENTON (MD)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:
Last Name:PENNICOOKE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-3577
Mailing Address - Fax:314-362-2107
Practice Address - Street 1:10 HOSPITAL DR
Practice Address - Street 2:DEPT NEUROLOGICAL SURGERY
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1659
Practice Address - Country:US
Practice Address - Phone:314-362-3577
Practice Address - Fax:314-362-2107
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020021408207T00000X, 207XS0117X, 207T00000X
NY288251207T00000X
CA160390207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200085861Medicaid