Basic Information
| Provider Information | |||||||||
| NPI: | 1922090075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENEMAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636256 CENTRAL CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135855507 | ||||||||
| FaxNumber: | 5135855511 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135843494 | ||||||||
| FaxNumber: | 5135844007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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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 | 2085R0001X | 35-05-1974 | OH | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0120692000 | 05 | WV | MEDICAID | 0591506 | 05 | OH | MEDICAID | 0000F5185 | 05 | NM | MEDICAID | 64785504 | 05 | KY | MEDICAID | 295801 | 01 | OH | BLACK LUNG | OTHER | P8B037061 | 05 | TX | MEDICAID | 0655279 | 01 | OH | AETNA | OTHER | 16-20999 | 01 | OH | UNITED HEALTHCARE | OTHER | 200039460A | 05 | IN | MEDICAID | 920000710 | 01 | OH | RAILROAD MEDICARE | OTHER |