Provider Demographics
NPI:1629020102
Name:BRENNER, CHRISTOPHER (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
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 1:9910 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRYSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-3612
Mailing Address - Country:US
Mailing Address - Phone:708-352-6166
Mailing Address - Fax:708-352-3864
Practice Address - Street 1:9910 W 55TH ST
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-3612
Practice Address - Country:US
Practice Address - Phone:708-352-6166
Practice Address - Fax:708-352-3864
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073572Medicaid
ILE19248Medicare UPIN