Healthcare Provider Details

I. General information

NPI: 1356563258
Provider Name (Legal Business Name): KRISTIN ROYCE BRODIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 FANCHER RD
BRIDGEWATER CORNERS VT
05035-9736
US

IV. Provider business mailing address

PO BOX 382
BRIDGEWATER CORNERS VT
05035-0382
US

V. Phone/Fax

Practice location:
  • Phone: 315-436-8864
  • Fax:
Mailing address:
  • Phone: 315-436-8864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number178242-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number1782421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: