Provider Demographics
NPI:1710966304
Name:BRENNAN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:511 RED RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ZION GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17985-9677
Mailing Address - Country:US
Mailing Address - Phone:570-384-0716
Mailing Address - Fax:
Practice Address - Street 1:700 E BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6835
Practice Address - Country:US
Practice Address - Phone:570-501-4156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058575L207ZC0500X
PAMD058474L207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019740530003Medicaid
PAH73643Medicare UPIN
PA06457Medicare PIN