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General NPI Number Information
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NPI Number | 1093723793
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Entity Type | Individual
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Provider Name | LARRY R BRAZLEY MD
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Gender | Male
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 06/07/2011
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Provider Practice Location Address
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Address Line | 255 E 90TH DR W1
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City | MERRILLVILLE
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State | IN
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Zip | 46410-8144
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Country | US
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Telephone | 219-791-0248
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Fax | 219-791-0251
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Provider Business Mailing Address
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Address Line | 55 E 86TH AVE PO BOX 10645
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City | MERRILLVILLE
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State | IN
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Zip | 46410-6382
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Country | US
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Telephone | 219-769-1670
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Fax | 219-738-6714
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 01032396
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License Number State | IN
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