Basic Information
| Provider Information | |||||||||
| NPI: | 1689661175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRENNAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | #405 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057649535 | ||||||||
| FaxNumber: | 5059247336 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | #405 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057649535 | ||||||||
| FaxNumber: | 5059247336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | AA5278 | AK | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 2002-0460 | NM | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 48805815 | 05 | NM | MEDICAID | MD5278 | 05 | AK | MEDICAID |