Healthcare Provider Details

I. General information

NPI: 1487819785
Provider Name (Legal Business Name): JACOB RAEMER BRODSKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE LO-367
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE LO-367
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 781-216-2849
  • Fax: 781-216-3155
Mailing address:
  • Phone: 781-216-2849
  • Fax: 781-216-3155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number246346
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: