MEDICARE: IVAN JAY BRODWYN DC

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	111N00000X	Chiropractor	DC1811	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7365	OTHER	GA	GRP NUMBER

General Provider Information

NPI Number	:	1538193503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN JAY BRODWYN DC

Provider Business Mailing Address
First Line	:	3624 EDGEWOOD RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-2184
Country	:	US
Telephone Number	:	706-563-3370
Fax Number	:	706-563-3501

Provider Business Practice Location Address
First Line	:	3624 EDGEWOOD RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-2184
Country	:	US
Telephone Number	:	706-563-3370
Fax Number	:	706-563-3501

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

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	01/15/2014

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