Provider Demographics
NPI:1710986369
Name:BRENNER, BARRY STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:STEVEN
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 1:455 TINA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3643
Mailing Address - Country:US
Mailing Address - Phone:215-322-2882
Mailing Address - Fax:
Practice Address - Street 1:2175 KNORR ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2307
Practice Address - Country:US
Practice Address - Phone:215-624-2491
Practice Address - Fax:215-624-4259
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021739E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0268562004OtherCIGNA HEALTHCARE
PA0058419000OtherINDEPENDENCE BLUE CROSS
PA19356OtherAENTAUSHEALTHCARE
B35275Medicare UPIN
PA19356OtherAENTAUSHEALTHCARE