1083086870 NPI number — CHARLES EDWARD BRIOSCHI JR. PA

Table of content: DR. MELISSA WORONOFF PSYD (NPI 1861671968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083086870 NPI number — CHARLES EDWARD BRIOSCHI JR. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIOSCHI
Provider First Name:
CHARLES
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083086870
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-452-3111
Provider Business Mailing Address Fax Number:
208-452-3666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 NW 16TH STREET
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-3111
Provider Business Practice Location Address Fax Number:
208-452-3666
Provider Enumeration Date:
10/20/2015

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: 363AM0700X , with the licence number:  PA-1317 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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