Provider Demographics
NPI:1215098983
Name:BRENTWOOD PEDIATRICS PC
Entity type:Organization
Organization Name:BRENTWOOD PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRMINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-918-8827
Mailing Address - Street 1:1600 S BRENTWOOD BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1301
Mailing Address - Country:US
Mailing Address - Phone:314-918-8827
Mailing Address - Fax:314-918-9391
Practice Address - Street 1:1600 S BRENTWOOD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-1301
Practice Address - Country:US
Practice Address - Phone:314-918-8827
Practice Address - Fax:314-918-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1P89208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F26879Medicare UPIN
F92249Medicare UPIN