MEDICARE: DR. MERRICK JAY BROMBERG 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	208000000X	Pediatrics Physician	036-060761	IL

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

General Provider Information

NPI Number	:	1659481778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MERRICK JAY BROMBERG D.O.

Provider Business Mailing Address
First Line	:	303 W LAKE ST
Second Line	:	SUITE 102
City	:	ADDISON
State	:	IL
Zip	:	60101-2586
Country	:	US
Telephone Number	:	630-543-3020
Fax Number	:	630-543-1551

Provider Business Practice Location Address
First Line	:	303 W LAKE ST
Second Line	:	SUITE 102
City	:	ADDISON
State	:	IL
Zip	:	60101-2586
Country	:	US
Telephone Number	:	630-543-3020
Fax Number	:	630-543-1551

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. MERRICK JAY BROMBERG D.O.” Practice Location

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