Healthcare Provider Details

I. General information

NPI: 1194714303
Provider Name (Legal Business Name): STEPHEN LOUIS BRENNEKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 SE SUNNYSIDE RD SUITE 130
CLACKAMAS OR
97015-5745
US

IV. Provider business mailing address

10121 SE SUNNYSIDE RD SUITE 130
CLACKAMAS OR
97015-5745
US

V. Phone/Fax

Practice location:
  • Phone: 503-766-3545
  • Fax: 503-342-3766
Mailing address:
  • Phone: 503-766-3545
  • Fax: 503-342-3766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD11314
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: