Provider Demographics
NPI:1972545929
Name:BRENNER, ILENE (MD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:RIKKI
Other - Last Name:BENATOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:880 DREWRY ST NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3811
Mailing Address - Country:US
Mailing Address - Phone:404-876-4034
Mailing Address - Fax:
Practice Address - Street 1:880 DREWRY ST NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3811
Practice Address - Country:US
Practice Address - Phone:404-876-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051120207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH79310Medicare UPIN