Provider Demographics
NPI:1235138769
Name:BRENNER, RICHARD PAUL (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PAUL
Last Name:BRENNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 KNORR ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2307
Mailing Address - Country:US
Mailing Address - Phone:215-338-6703
Mailing Address - Fax:
Practice Address - Street 1:2175 KNORR ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2307
Practice Address - Country:US
Practice Address - Phone:215-624-2491
Practice Address - Fax:215-624-4259
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003538L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0268562004OtherCIGNA HEALTHCARE
PA0058482000OtherINDEPENDENCE BLUE CROSS
PA19355OtherAETNAUSHEALTHCARE
PA0268562004OtherCIGNA HEALTHCARE
PA19355OtherAETNAUSHEALTHCARE