Healthcare Provider Details

I. General information

NPI: 1104825959
Provider Name (Legal Business Name): BRYANN BROMLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKLINE PL SUITE 506
BROOKLINE MA
02445-7224
US

IV. Provider business mailing address

340 MAIN ST STE. 670
WORCESTER MA
01608-1604
US

V. Phone/Fax

Practice location:
  • Phone: 617-739-0245
  • Fax: 617-738-6703
Mailing address:
  • Phone: 617-724-2229
  • Fax: 617-724-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number56429
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number56429
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: