1306894753 NPI number — DR. LAURENCE HARVEY BRENNER MD

Table of content: WHITNEY BARNES (NPI 1841346723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306894753 NPI number — DR. LAURENCE HARVEY BRENNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNER
Provider First Name:
LAURENCE
Provider Middle Name:
HARVEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRENNER
Provider Other First Name:
LAURENCE
Provider Other Middle Name:
H
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1306894753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 CYPRESS HILLS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32724-7352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-489-8524
Provider Business Mailing Address Fax Number:
386-624-6297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 HARDEN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33803-7952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-687-1250
Provider Business Practice Location Address Fax Number:
863-687-1258
Provider Enumeration Date:
05/05/2006

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: 174400000X , with the licence number:  ME91864 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0122X , with the licence number: ME91864 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0105X , with the licence number: ME91864 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K7473 . This is a "MEDICARE GROUP PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274526700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52154A . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6137800001 . This is a "MEDICARE NSC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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