Healthcare Provider Details

I. General information

NPI: 1487188504
Provider Name (Legal Business Name): NICHOLAS BRENNECKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2017
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE (UNIVERSITY HOSPITALS, CLEVELAND MEDICAL CENTER)
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

11100 EUCLID AVE (UNIVERSITY HOSPITALS, CLEVELAND MEDICAL CENTER)
CLEVELAND OH
44106-1716
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number35.142731
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: