Healthcare Provider Details

I. General information

NPI: 1467714824
Provider Name (Legal Business Name): MARK JOSEPH BROERING JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506A MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

375 DIXMYTH AVE
CINCINNATI OH
45220-2475
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-9898
  • Fax: 513-865-9900
Mailing address:
  • Phone: 513-862-3562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number35.130473
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35.130473
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: