Basic Information
| Provider Information | |||||||||
| NPI: | 1235168980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 2016B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142515860 | ||||||||
| FaxNumber: | 3142515861 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | SUITE 2016B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142515860 | ||||||||
| FaxNumber: | 3142515861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRENNER | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3142515860 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 2000169319 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.