Provider Demographics
NPI:1659310563
Name:BRENNER, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
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 1:7 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4566
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:1350 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2408
Practice Address - Country:US
Practice Address - Phone:864-271-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC071255Medicaid
SC57-1004971003OtherBCBS OF SC
SC4556601OtherAETNA
SC071255Medicaid