Basic Information
| Provider Information | |||||||||
| NPI: | 1417917493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENIZER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LIANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHUEY | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | LIANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3 WALNUT ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177610208 | ||||||||
| FaxNumber: | 7177612023 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 RED HILL CT | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170748706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175673151 | ||||||||
| FaxNumber: | 7175677571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD063330L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 370018589 | 01 | PA | RR MEDICARE | OTHER |