Provider Demographics
NPI:1396901641
Name:BRENT R PALMER LC
Entity type:Organization
Organization Name:BRENT R PALMER LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-966-7570
Mailing Address - Street 1:2315 DOUGHERTY FERRY RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 DOUGHERTY FERRY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3383
Practice Address - Country:US
Practice Address - Phone:314-966-7570
Practice Address - Fax:314-966-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOB18594Medicare UPIN