Provider Demographics
NPI:1376753277
Name:SMITH, BRENNEN D (DO)
Entity Type:Individual
Prefix:
First Name:BRENNEN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:4784 AMBER VALLEY PKWY S
Mailing Address - Street 2:CHI PROVIDER ENROLLMENT - FARGO DIVISON
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8614
Mailing Address - Country:US
Mailing Address - Phone:701-237-8072
Mailing Address - Fax:937-599-1730
Practice Address - Street 1:2400 ST FRANCIS DR
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1025
Practice Address - Country:US
Practice Address - Phone:218-643-3000
Practice Address - Fax:218-643-0850
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND15379207X00000X
OH34.010178207XS0117X
MN61204207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1471472Medicaid
OH3158630Medicaid
OH000000480404OtherOH MEDICAID UNISON
WV3810022462Medicaid