MEDICARE: WILLIAM MICHAEL BRENNAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	5302027722	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5302027722	OTHER	MI	STATE LICENSE

General Provider Information

NPI Number	:	1578100376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM MICHAEL BRENNAN

Provider Business Mailing Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-2467
Country	:	US
Telephone Number	:	810-664-0391
Fax Number	:	810-664-7079

Provider Business Practice Location Address
First Line	:	540 S MAIN ST
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-2467
Country	:	US
Telephone Number	:	810-664-0391
Fax Number	:	810-664-7079

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2019
Last Update Date	:	11/30/2019

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