1912276643 NPI number — MARC A. BRENNER, D.P.M., PLLC

Table of content: (NPI 1912276643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912276643 NPI number — MARC A. BRENNER, D.P.M., PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARC A. BRENNER, D.P.M., PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARC ALAN BRENNER D.P.M., PC
Provider Other Organization Name Type Code:
4
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:
1912276643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
83 WHEATLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD WESTBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11568-1210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-355-2277
Provider Business Mailing Address Fax Number:
516-626-9243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 MARCUS AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE SUCCESS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-355-2277
Provider Business Practice Location Address Fax Number:
516-626-9243
Provider Enumeration Date:
12/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WELCH
Authorized Official First Name:
SHARESE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
718-573-1123

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  N002371-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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