MEDICARE: DR. BRANDON MICAH BREVIG D.O.

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	208100000X	Physical Medicine & Rehabilitation Physician	11-6037195	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11-6037195	OTHER	NY	GERALD TEPLITZ, DO

General Provider Information

NPI Number	:	1306057641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON MICAH BREVIG D.O.

Provider Business Mailing Address
First Line	:	2032 E SIDEWINDER DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5867
Country	:	US
Telephone Number	:	208-488-8408
Fax Number	:	888-913-3862

Provider Business Practice Location Address
First Line	:	302 W IDAHO ST
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-6039
Country	:	US
Telephone Number	:	208-994-4962
Fax Number	:	888-913-3862

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

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	01/06/2016

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