=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598091100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERBERT E BROOKS MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2009
-----------------------------------------------------
Last Update Date | 01/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2126 HIGHWAY 173
-----------------------------------------------------
City | BONIFAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32425-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-547-4556
-----------------------------------------------------
Fax | 850-547-4511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 699
-----------------------------------------------------
City | BONIFAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32425-0699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-547-4556
-----------------------------------------------------
Fax | 850-547-4511
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HERBERT EDWIN BROOKS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-547-4793
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | ME11075
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------