Healthcare Provider Details

I. General information

NPI: 1710986369
Provider Name (Legal Business Name): BARRY STEVEN BRENNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 KNORR ST
PHILADELPHIA PA
19149-2307
US

IV. Provider business mailing address

455 TINA DR
SOUTHAMPTON PA
18966-3643
US

V. Phone/Fax

Practice location:
  • Phone: 215-624-2491
  • Fax: 215-624-4259
Mailing address:
  • Phone: 215-322-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD021739E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: