Provider Demographics
NPI:1669588406
Name:FENNELLY, BRYAN WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:WILLIAM
Last Name:FENNELLY
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 1:8 SHUNPIKE RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2740
Mailing Address - Country:US
Mailing Address - Phone:973-660-0084
Mailing Address - Fax:973-966-0332
Practice Address - Street 1:8 SHUNPIKE RD
Practice Address - Street 2:SUITE 9
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-2740
Practice Address - Country:US
Practice Address - Phone:973-660-0084
Practice Address - Fax:973-966-0332
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA060229002084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6255809Medicaid
NJFE502735Medicare ID - Type Unspecified
NJ6255809Medicaid