MEDICARE: EDWARD JOHN BROCCOLI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	1934481	NY
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	1934481	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0004487677	OTHER	NY	AETNA US HEALTHCARE PPO
2	5398369	OTHER	NY	HEALTH NET
3	8K819	OTHER	NY	EMPIRE BCBS
4	3129240	OTHER	NY	AETNA US HEALTHCARE HMO
5	5398370	OTHER	NY	GHI
6	P2823545	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1609866060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD JOHN BROCCOLI MD

Provider Business Mailing Address
First Line	:	16 S BEDFORD RD
Second Line	:	3W
City	:	CHAPPAQUA
State	:	NY
Zip	:	10514-3464
Country	:	US
Telephone Number	:	914-844-2864
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 S BEDFORD RD
Second Line	:	3W
City	:	CHAPPAQUA
State	:	NY
Zip	:	10514-3464
Country	:	US
Telephone Number	:	914-844-2864
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	01/11/2024

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