1245730530 NPI number — THOMAS EUGENE BROFFMAN

Table of content: THOMAS EUGENE BROFFMAN (NPI 1245730530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245730530 NPI number — THOMAS EUGENE BROFFMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROFFMAN
Provider First Name:
THOMAS
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROFFMAN
Provider Other First Name:
THOMAS
Provider Other Middle Name:
EUGENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245730530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANIELSON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06239-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-338-5605
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 THOMPSON RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-943-2600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2018

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: 104100000X , with the licence number:  100176 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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