Provider Demographics
NPI:1811908593
Name:BROENNLE, ALBERT M (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:M
Last Name:BROENNLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 N 20TH STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103
Mailing Address - Country:US
Mailing Address - Phone:215-977-8100
Mailing Address - Fax:215-977-8351
Practice Address - Street 1:34TH STREET & CIVIC CENTER BLVD
Practice Address - Street 2:SUITE 9329
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1858
Practice Address - Fax:215-590-1415
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014236E207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006842280Medicaid
PA117999OtherMEDICARE ID
PA0006842280Medicaid