Provider Demographics
NPI:1093814857
Name:BRENNAN, TRACY E (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:E
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 RETREAT AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106
Mailing Address - Country:US
Mailing Address - Phone:860-525-9767
Mailing Address - Fax:860-525-9782
Practice Address - Street 1:136 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-547-0306
Practice Address - Fax:860-525-9782
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028642207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001286427Medicaid
CT001286427Medicaid
160001588Medicare ID - Type Unspecified