Provider Demographics
NPI:1366899841
Name:BRENNEMAN, RANDALL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:JAMES
Last Name:BRENNEMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4921 PARKVIEW PL
Mailing Address - Street 2:DEPT RADIATION ONCOLOGY, LL
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1032
Mailing Address - Country:US
Mailing Address - Phone:314-747-7236
Mailing Address - Fax:314-747-9557
Practice Address - Street 1:701 NORTH 1ST STREET RADIATION ONCOLOGY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-1032
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:314-747-9557
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20210194672085R0001X, 2085R0001X
IL0361565982085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200061655Medicaid