Provider Demographics
NPI:1366492027
Name:BRENNER, AMY G (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:G
Last Name:BRENNER
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:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47701-0078
Mailing Address - Country:US
Mailing Address - Phone:800-467-2392
Mailing Address - Fax:812-471-6650
Practice Address - Street 1:7593 TYLERS PLACE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6312
Practice Address - Country:US
Practice Address - Phone:513-777-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078006207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H19573Medicare UPIN