Provider Demographics
NPI:1770582793
Name:BRENNAN, PATRICK R (DO)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:R
Last Name:BRENNAN
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 1:22024 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9410
Mailing Address - Country:US
Mailing Address - Phone:248-437-2525
Mailing Address - Fax:248-437-2526
Practice Address - Street 1:22024 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9410
Practice Address - Country:US
Practice Address - Phone:248-437-2525
Practice Address - Fax:248-437-2526
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
MIPB5101014989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7323572OtherAETNA
MI5631170OtherBLUE CROSS PROVIDER I.D.
MI139314OtherPREFERRED CHOICE
MI139314OtherCARE CHOICE
MI0N94720/0N9472002Medicare ID - Type UnspecifiedGROUP #/INDIVIDUAL #
MI139314OtherCARE CHOICE