1235156258 NPI number — BRENNA WYNNE MD

Table of content: BRENNA WYNNE MD (NPI 1235156258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235156258 NPI number — BRENNA WYNNE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYNNE
Provider First Name:
BRENNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235156258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 COOPER PLZ
Provider Second Line Business Practice Location Address:
COOPER UNIVERISRY EMERGENCY PHYSICIANS
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-342-2351
Provider Business Practice Location Address Fax Number:
856-968-8272
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MA08014100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1321749 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60025839 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 01077790000 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0109983 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2751473000 . This is a "AMERIHEALTH/KEYSTON/IBC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5618198 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P00376573 . This is a "RR MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2679053 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3698442 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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