Provider Demographics
NPI:1649658949
Name:LALLY, BRENDAN
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:LALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 SE 17TH ST APT 451
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-3142
Mailing Address - Country:US
Mailing Address - Phone:727-686-4630
Mailing Address - Fax:
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-355-5199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-07
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME136054207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine