Healthcare Provider Details

I. General information

NPI: 1417268046
Provider Name (Legal Business Name): JACK L BRENNER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1974 MAPLE HILL ST SUITE 6
YORKTOWN HTS NY
10598-4190
US

IV. Provider business mailing address

1974 MAPLE HILL ST SUITE 6
YORKTOWN HTS NY
10598-4190
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-5596
  • Fax: 914-962-5919
Mailing address:
  • Phone: 914-962-5596
  • Fax: 914-962-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1064781
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number1064781
License Number StateNY

VIII. Authorized Official

Name: DR. JACK L BRENNER
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 914-962-5596