Healthcare Provider Details

I. General information

NPI: 1922129659
Provider Name (Legal Business Name): BRODELL MEDICAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 E MARKET ST
WARREN OH
44483-6204
US

IV. Provider business mailing address

2660 E MARKET ST
WARREN OH
44483-6204
US

V. Phone/Fax

Practice location:
  • Phone: 330-393-4000
  • Fax: 330-392-5870
Mailing address:
  • Phone: 330-393-4000
  • Fax: 330-392-5870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35055185
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35051515
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35055186
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35051453
License Number StateOH

VIII. Authorized Official

Name: ROBERT T BRODELL
Title or Position: PRESIDENT
Credential: MD
Phone: 330-393-4000