Provider Demographics
NPI:1770513319
Name:ALLEN, BRENT T (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:T
Last Name:ALLEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-991-4644
Mailing Address - Fax:866-342-0133
Practice Address - Street 1:555 N NEW BALLAS RD
Practice Address - Street 2:DIV SURG VASCULAR, STE 265
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6825
Practice Address - Country:US
Practice Address - Phone:314-991-4644
Practice Address - Fax:866-342-0133
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2B052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202398723Medicaid
MO202398723Medicaid
MO000094556Medicare ID - Type Unspecified
20043747Medicare PIN