1316141195 NPI number — DR. SARAH BROSKI GENDERNALIK DO

Table of content: DR. SARAH BROSKI GENDERNALIK DO (NPI 1316141195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316141195 NPI number — DR. SARAH BROSKI GENDERNALIK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GENDERNALIK
Provider First Name:
SARAH
Provider Middle Name:
BROSKI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROSKI
Provider Other First Name:
SARAH
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316141195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
147 PEACE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT JOSEPH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49085-9146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-429-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
147 PEACE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-429-5000
Provider Business Practice Location Address Fax Number:
269-429-5081
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  5101018001 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com