1649201336 NPI number — MR. GERALD EDWIN BRENNEMAN P.A.C.

Table of content: MR. GERALD EDWIN BRENNEMAN P.A.C. (NPI 1649201336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649201336 NPI number — MR. GERALD EDWIN BRENNEMAN P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENNEMAN
Provider First Name:
GERALD
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
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:
1649201336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 819
Provider Second Line Business Mailing Address:
25 NORTH JOHNSON ST.
Provider Business Mailing Address City Name:
COATS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27521-0819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-897-6423
Provider Business Mailing Address Fax Number:
910-897-2540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COATS MEDICAL CLINIC
Provider Second Line Business Practice Location Address:
25 NORTH JOHNSON ST.
Provider Business Practice Location Address City Name:
COATS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-897-6423
Provider Business Practice Location Address Fax Number:
910-897-2540
Provider Enumeration Date:
07/05/2006

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: 363A00000X , with the licence number:  101469 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101469 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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