Healthcare Provider Details

I. General information

NPI: 1205032463
Provider Name (Legal Business Name): WEST BROOKFIELD FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 NORTH MAIN ST
WEST BROOKFIELD MA
01585
US

IV. Provider business mailing address

46 NORTH MAIN STREET
WEST BROOKFIELD MA
01585-1044
US

V. Phone/Fax

Practice location:
  • Phone: 508-867-8977
  • Fax: 508-867-7361
Mailing address:
  • Phone: 508-867-8977
  • Fax: 508-867-7361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number73319
License Number StateMA

VIII. Authorized Official

Name: DR. GWEN MARIE BROZ
Title or Position: DOCTOR
Credential: D.O.
Phone: 508-867-8977