Healthcare Provider Details

I. General information

NPI: 1801889183
Provider Name (Legal Business Name): ROBERT WRIGHT BRODIE PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 HOSPITAL LN SUITE 202
PERRYVILLE MO
63775-1276
US

IV. Provider business mailing address

206 HOSPITAL LN SUITE 202
PERRYVILLE MO
63775-1276
US

V. Phone/Fax

Practice location:
  • Phone: 573-768-3396
  • Fax: 573-768-3397
Mailing address:
  • Phone: 573-768-3396
  • Fax: 573-768-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2001023599
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: