Provider Demographics
NPI:1881868099
Name:STEPHEN L BRENNEKE, M.D., P.C.
Entity Type:Organization
Organization Name:STEPHEN L BRENNEKE, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRENNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-252-0221
Mailing Address - Street 1:3510 NE 122ND AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1500
Mailing Address - Country:US
Mailing Address - Phone:503-252-0221
Mailing Address - Fax:503-253-4769
Practice Address - Street 1:3510 NE 122ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1500
Practice Address - Country:US
Practice Address - Phone:503-252-0221
Practice Address - Fax:503-253-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11314174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR112187Medicare PIN