Provider Demographics
NPI:1902873409
Name:BRENNER, MARK J (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BRENNER
Suffix:
Gender:
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:PO BOX 11760
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4008
Mailing Address - Country:US
Mailing Address - Phone:888-402-7256
Mailing Address - Fax:888-902-1099
Practice Address - Street 1:1 EATON PL STE 100
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-363-6881
Practice Address - Fax:508-363-7170
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00416402085R0001X
MA540992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085074AMedicaid
MD920007556OtherRAILROAD MEDICARE
MD168741700Medicaid
MD920004528OtherRR MEDICARE
MD920007556OtherRAILROAD MEDICARE
MD920004528OtherRR MEDICARE
MD605L047DMedicare PIN
E12666Medicare UPIN