Provider Demographics
NPI:1174565832
Name:DRS. BRENNER & MITNICK, P.A.
Entity type:Organization
Organization Name:DRS. BRENNER & MITNICK, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-922-1133
Mailing Address - Street 1:3408 ENGLEMEADE RD
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-1601
Mailing Address - Country:US
Mailing Address - Phone:410-484-1416
Mailing Address - Fax:
Practice Address - Street 1:5400 OLD COURT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-922-1133
Practice Address - Fax:410-922-9710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD383081100Medicaid
MD383081100Medicaid
S230BRMedicare ID - Type Unspecified