Provider Demographics
NPI:1235168980
Name:PEDIATRIX MEDICAL GROUP
Entity Type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-251-5860
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2016B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-5860
Mailing Address - Fax:314-251-5861
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 2016B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-5860
Practice Address - Fax:314-251-5861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001693192080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty