Healthcare Provider Details

I. General information

NPI: 1073559837
Provider Name (Legal Business Name): JOHN SJ BROOKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SPRUCE STREET 6 PRESTON
PHILADELPHIA PA
19107
US

IV. Provider business mailing address

800 SPRUCE STREET 6 PRESTON
PHILADELPHIA PA
19107
US

V. Phone/Fax

Practice location:
  • Phone: 215-829-3541
  • Fax: 215-829-7564
Mailing address:
  • Phone: 215-829-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZI0100X
TaxonomyImmunopathology Physician
License NumberMD016947E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD016947E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD016947E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: