Basic Information
Provider Information | |||||||||
NPI: | 1023146776 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRENNER | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3621 S STATE ST | ||||||||
Address2: | 700 KMS PLACE | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481081633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7349362047 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19900 HAGGERTY RD | ||||||||
Address2: | SUITE 103 | ||||||||
City: | LIVONIA | ||||||||
State: | MI | ||||||||
PostalCode: | 481521054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344327634 | ||||||||
FaxNumber: | 7344327660 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2007 | ||||||||
LastUpdateDate: | 10/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 4301102509 | MI | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YX0007X | 036-121585 | IL | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0905X | 036-121585 | IL | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207YS0012X | 4301102509 | MI | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | 207YS0123X | 4301102509 | MI | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
ID Information
ID | Type | State | Issuer | Description | 036121585 | 05 | IL |   | MEDICAID |