Healthcare Provider Details

I. General information

NPI: 1952468670
Provider Name (Legal Business Name): MARY ELIZABETH BRENNAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 FAIRFIELD LOOP RD
CROWNSVILLE MD
21032-2006
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 410-987-6338
  • Fax:
Mailing address:
  • Phone: 505-262-7963
  • Fax: 505-232-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94-199
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number94-199
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number94-199
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0095712
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: