Provider Demographics
NPI:1114992674
Name:BRENNER, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BRENNER
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 1:814 PIERCE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1058
Mailing Address - Country:US
Mailing Address - Phone:712-226-2600
Mailing Address - Fax:712-226-2605
Practice Address - Street 1:3250 PLAZA DR
Practice Address - Street 2:
Practice Address - City:SOUTH SIOUX CITY
Practice Address - State:NE
Practice Address - Zip Code:68776-3144
Practice Address - Country:US
Practice Address - Phone:402-412-4220
Practice Address - Fax:402-412-4222
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35697207Q00000X
NE23232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0092080Medicaid
IA1454017Medicaid
IA1454017Medicaid
IA0092080Medicaid
I19070Medicare UPIN