Provider Demographics
NPI:1174523443
Name:BRENNAN, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:UNITED MEDICAL ASSOCIATES, PC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-763-8100
Mailing Address - Fax:607-729-8866
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:STE 455
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2161
Practice Address - Country:US
Practice Address - Phone:607-763-8100
Practice Address - Fax:607-763-8048
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-09-15
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Provider Licenses
StateLicense IDTaxonomies
NY217717208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02082319Medicaid
NYJ400059224Medicare PIN
NYCC0285Medicare ID - Type Unspecified
NY02082319Medicaid