Provider Demographics
NPI:1467489435
Name:BRENNER, ANDREW S (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:S
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 1:1570 PASEO GRANDE
Mailing Address - Street 2:#2024
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8523
Mailing Address - Country:US
Mailing Address - Phone:217-621-9007
Mailing Address - Fax:
Practice Address - Street 1:1570 PASEO GRANDE
Practice Address - Street 2:#2024
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8523
Practice Address - Country:US
Practice Address - Phone:217-621-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052639207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036052639Medicaid
ILD15952Medicare UPIN
ILK16101Medicare ID - Type Unspecified
AZZ111408Medicare PIN