MEDICARE: JORDAN M BROMBERG M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME0045084	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275518391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN M BROMBERG M.D.

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34995-0417
Country	:	US
Telephone Number	:	772-223-5665
Fax Number	:	772-223-5646

Provider Business Practice Location Address
First Line	:	1095 NW SAINT LUCIE WEST BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-1719
Country	:	US
Telephone Number	:	772-223-5665
Fax Number	:	772-223-5646

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	10/09/2020

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