Provider Demographics
NPI:1316986540
Name:BRENNAN, RICHARD XAVIER (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:XAVIER
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 230
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-849-3711
Mailing Address - Fax:314-849-0235
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:STE 230
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-849-3711
Practice Address - Fax:314-849-0235
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR6H23207V00000X
IL336-069221207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO156440092OtherMEDICARE PTAN #
MO206853004Medicaid
MO206853004Medicaid