Provider Demographics
NPI:1538165345
Name:BRENNAN, TERESA L (MD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 LANGHORNE RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1400
Mailing Address - Country:US
Mailing Address - Phone:434-384-3047
Mailing Address - Fax:
Practice Address - Street 1:2138 LANGHORNE RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1400
Practice Address - Country:US
Practice Address - Phone:434-384-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036819208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
203639329OtherUNITED HEALTHCARE PROVIDE
203639329OtherPCHP PROVIDER NUMBER
329098OtherSOUTHERN HEALTH PROVIDER
010218942OtherVA PREMIER
186281OtherANTHEM PROVIDER NUMBER
7024783OtherCIGNA PROVIDER NUMBER
VA010218942Medicaid
91916OtherSENTARA/OPTIMA PROVIDER N
203639329003OtherTRICARE PROVIDER NUMBER
203639329OtherPCHP PROVIDER NUMBER
VAVV0586AMedicare PIN