Provider Demographics
NPI:1578535563
Name:BRENNAMAN, BRUCE HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:HOWARD
Last Name:BRENNAMAN
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 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-660-6148
Mailing Address - Fax:706-660-2843
Practice Address - Street 1:920 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1524
Practice Address - Country:US
Practice Address - Phone:706-649-6600
Practice Address - Fax:706-649-6614
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31709208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL008902960Medicaid
GA000318117BMedicaid
GA52244152-005OtherBCBSGA
GA52244152-005OtherBCBS
AL600-37660OtherBCBSAL
AL154485OtherMEDICAID-OFFICE
GA000318117GOtherMEDICAID-OFFICE
GAD21900Medicare UPIN