Provider Demographics
NPI:1669468831
Name:BRENNEMAN, DOUGLAS (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:BRENNEMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:717-221-5673
Practice Address - Street 1:2500 DELTA RD
Practice Address - Street 2:
Practice Address - City:BROGUE
Practice Address - State:PA
Practice Address - Zip Code:17309-9106
Practice Address - Country:US
Practice Address - Phone:717-927-8434
Practice Address - Fax:717-927-6274
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI03192Medicare UPIN
PA077530S6MMedicare ID - Type Unspecified