Basic Information
| Provider Information | |||||||||
| NPI: | 1366899841 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNEMAN | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | DEPT RADIATION ONCOLOGY, LL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147477236 | ||||||||
| FaxNumber: | 3147479557 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL | ||||||||
| Address2: | DEPT RADIATION ONCOLOGY, LL | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147477236 | ||||||||
| FaxNumber: | 3147479557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2016 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 2021019467 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200061655 | 05 | MO | MEDICAID |