Healthcare Provider Details

I. General information

NPI: 1639134604
Provider Name (Legal Business Name): JONATHAN J BRODIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 11/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E TYRANENA PARK RD
LAKE MILLS WI
53551-9678
US

IV. Provider business mailing address

200 E TYRANENA PARK RD
LAKE MILLS WI
53551-9678
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-3113
  • Fax:
Mailing address:
  • Phone: 920-648-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30363
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30363-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: