Basic Information
| Provider Information | |||||||||
| NPI: | 1811908593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROENNLE | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N 20TH STREET | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159778100 | ||||||||
| FaxNumber: | 2159778351 | ||||||||
| Practice Location | |||||||||
| Address1: | 34TH STREET & CIVIC CENTER BLVD | ||||||||
| Address2: | SUITE 9329 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901858 | ||||||||
| FaxNumber: | 2155901415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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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 | 207L00000X | MD014236E | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | MD014236E | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0006842280 | 05 | PA | MEDICAID | 117999 | 01 | PA | MEDICARE ID | OTHER |