1275538423 NPI number — MR. MICHAEL A BRODSKY MD

Table of content: DR. JAMES TATE MD (NPI 1649254426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275538423 NPI number — MR. MICHAEL A BRODSKY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODSKY
Provider First Name:
MICHAEL
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1275538423
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 N TUSTIN AVE
Provider Second Line Business Mailing Address:
#706
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-3612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-568-6600
Provider Business Mailing Address Fax Number:
714-245-0260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 N TUSTIN AVE
Provider Second Line Business Practice Location Address:
SUITE 706
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-568-6600
Provider Business Practice Location Address Fax Number:
714-245-0260
Provider Enumeration Date:
06/15/2005

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: 174400000X , with the licence number:  MD11837 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: MD11837 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 57286901 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0059850 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000255315 . This is a "HMSA BILLING NUMBER" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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