Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0114X | Adult Reconstructive Orthopaedic Surgeon | MD11314 | OR |
NPI | 1194714303 |
---|---|
Provider Name | Dr. Stephen Louis Brenneke |
First Address | Clackamas, OR 97015-5745 |
Second Address | Clackamas, OR 97015-5745 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2005 |
Last Update Date | 01/03/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
112187 | MEDICARE GROUP (01) | OR |
C92279 | (02) | OR |