Healthcare Provider Details

I. General information

NPI: 1790734713
Provider Name (Legal Business Name): MICHAEL BRODY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD ANESTHESIA DEPARTMENT
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

901 MACARTHUR BLVD ANESTHESIA DEPARTMENT
MUNSTER IN
46321-2901
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1600
  • Fax: 219-513-1127
Mailing address:
  • Phone: 219-836-7040
  • Fax: 219-513-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01051737A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: