Healthcare Provider Details

I. General information

NPI: 1710966304
Provider Name (Legal Business Name): JOHN BRENNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E BROAD ST
HAZLETON PA
18201-6835
US

IV. Provider business mailing address

511 RED RIDGE RD
ZION GROVE PA
17985-9677
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-4156
  • Fax:
Mailing address:
  • Phone: 570-384-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberMD058575L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD058474L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0019740530003
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: