Provider Demographics
NPI:1194818484
Name:BRENNAN, GARY B (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
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 1:2689 STRUTHMORE DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45806-1333
Mailing Address - Country:US
Mailing Address - Phone:419-979-8267
Mailing Address - Fax:
Practice Address - Street 1:23625 COMMERCE PARK DR SUITE 204
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-255-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350869252085R0202X
OH35-869252085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH88652Medicare UPIN
OHBR4251472Medicare PIN
OHBR4176098Medicare PIN