Basic Information
| Provider Information | |||||||||
| NPI: | 1164459798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNEY | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 W. IRONWOOD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COEUR D'ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087651455 | ||||||||
| FaxNumber: | 2086678655 | ||||||||
| Practice Location | |||||||||
| Address1: | 980 W. IRONWOOD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | COEUR D'ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087651455 | ||||||||
| FaxNumber: | 2086678655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M-8797 | ID | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | M8797 | ID | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 806682500 | 05 | ID | MEDICAID |