Provider Demographics
NPI:1417268046
Name:JACK L BRENNER MD PC
Entity Type:Organization
Organization Name:JACK L BRENNER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-962-5596
Mailing Address - Street 1:1974 MAPLE HILL ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:YORKTOWN HTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4190
Mailing Address - Country:US
Mailing Address - Phone:914-962-5596
Mailing Address - Fax:914-962-5919
Practice Address - Street 1:1974 MAPLE HILL ST
Practice Address - Street 2:SUITE 6
Practice Address - City:YORKTOWN HTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4190
Practice Address - Country:US
Practice Address - Phone:914-962-5596
Practice Address - Fax:914-962-5919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1064781207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC11424Medicare UPIN
NY566821Medicare PIN