Healthcare Provider Details

I. General information

NPI: 1568403418
Provider Name (Legal Business Name): ROGER THOMAS BRILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 NW 9TH BLVD
GAINESVILLE FL
32605-4205
US

IV. Provider business mailing address

6520 NW 9TH BLVD
GAINESVILLE FL
32605-4205
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-7987
  • Fax: 352-331-2787
Mailing address:
  • Phone: 352-331-7987
  • Fax: 352-331-2787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME0020528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: