Provider Demographics
NPI:1992818132
Name:BRENNER, ADAM (MD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:BRENNER
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-334-5606
Mailing Address - Fax:
Practice Address - Street 1:2776 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-5864
Practice Address - Country:US
Practice Address - Phone:239-334-5606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83198207P00000X
WAMD00078712207PE0005X
WAMD00048712207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279194OtherAVMED
WA8501967Medicaid
FL220945OtherAMERIGROUP
FL265736800Medicaid
FL47894OtherBLUE CROSS BLUE SHIELD
FL47894OtherBLUE CROSS BLUE SHIELD
FLH58504Medicare UPIN
WA8501967Medicaid
FL265736800Medicaid
FLP00060664Medicare PIN