Provider Demographics
NPI:1255391397
Name:BRENNER, ELAINE M (MD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:M
Last Name:BRENNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:2150
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2184
Mailing Address - Country:US
Mailing Address - Phone:248-926-6610
Mailing Address - Fax:248-926-6611
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:2150
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2184
Practice Address - Country:US
Practice Address - Phone:248-926-6610
Practice Address - Fax:248-926-6611
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053483207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00055649OtherRAILROAD MEDICARE
MI0F37550OtherBCBSM
MI383468933OtherCOMMERCIAL INSURANCE CO.
MIF01718OtherHAP
MI0F37550OtherBCN
MI104530972Medicaid
MIP00055649OtherRAILROAD MEDICARE
MIM89900027Medicare ID - Type Unspecified