Provider Demographics
NPI:1477533933
Name:BRENNAN, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
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:PO BOX 5307
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250-5307
Mailing Address - Country:US
Mailing Address - Phone:803-256-3534
Mailing Address - Fax:803-254-7032
Practice Address - Street 1:1740 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-256-3534
Practice Address - Fax:803-254-7032
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC126107Medicaid
SC570935648OtherEIN
D18333Medicare UPIN
SC110049275Medicare PIN
SCD183334019Medicare PIN