Provider Demographics
NPI:1346229424
Name:BRENNAN, CHARLES G (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COLBY ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970
Mailing Address - Country:US
Mailing Address - Phone:978-745-6282
Mailing Address - Fax:978-745-1127
Practice Address - Street 1:9 COLBY ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-745-6282
Practice Address - Fax:978-745-1127
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA28012207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2031426Medicaid
MAB97450Medicare ID - Type Unspecified
MAD2810201Medicare PIN
B97450Medicare UPIN