1639144595 NPI number — DR. JEROLD BARRY BRENOWITZ MD

Table of content: DR. JEROLD BARRY BRENOWITZ MD (NPI 1639144595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639144595 NPI number — DR. JEROLD BARRY BRENOWITZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENOWITZ
Provider First Name:
JEROLD
Provider Middle Name:
BARRY
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:
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:
1639144595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 N LAKE DR
Provider Second Line Business Mailing Address:
703
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-271-5119
Provider Business Mailing Address Fax Number:
414-271-3756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2315 N LAKE DR
Provider Second Line Business Practice Location Address:
703
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-271-5119
Provider Business Practice Location Address Fax Number:
414-271-3756
Provider Enumeration Date:
02/22/2006

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: 208G00000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30326200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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