MEDICARE: AMANDA BRENNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	ME158502	FL
3	207Q00000X	Family Medicine Physician	ME158502	FL
4	208100000X	Physical Medicine & Rehabilitation Physician	ME158502	FL
5	208M00000X	Hospitalist Physician	ME158502	FL

General Provider Information

NPI Number	:	1104445113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA BRENNER MD

Provider Business Mailing Address
First Line	:	2001 KINGSLEY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-5148
Country	:	US
Telephone Number	:	904-639-2000
Fax Number	:	904-639-2015

Provider Business Practice Location Address
First Line	:	2436 UNIVERSITY BLVD W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2002
Country	:	US
Telephone Number	:	904-916-1845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	08/21/2025

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