Healthcare Provider Details

I. General information

NPI: 1023433836
Provider Name (Legal Business Name): KEVIN BRENNER, MD, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 NORTH ROXBURY DRIVE SUITE 800
BEVERLY HILLS CA
90210
US

IV. Provider business mailing address

465 NORTH ROXBURY DRIVE SUITE 800
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 310-777-5400
  • Fax: 310-388-5352
Mailing address:
  • Phone: 310-777-5400
  • Fax: 310-388-5352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA79032
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberA79032
License Number StateCA

VIII. Authorized Official

Name: KEVIN BRENNER
Title or Position: PRESIDENT
Credential: MD
Phone: 310-777-5400