Provider Demographics
NPI:1043261316
Name:BRENNAN, J KELLEY (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:KELLEY
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5969 EAST BROAD STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213
Mailing Address - Country:US
Mailing Address - Phone:614-864-6010
Mailing Address - Fax:614-864-0306
Practice Address - Street 1:5969 EAST BROAD STREET
Practice Address - Street 2:2ND FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213
Practice Address - Country:US
Practice Address - Phone:614-864-6010
Practice Address - Fax:614-864-0306
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35033636B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0454119Medicaid
OH0454119Medicaid
OHCA9180583Medicare ID - Type Unspecified