MEDICARE: DR. SUSAN BROKAW M.D.

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	57617	OH

General Provider Information

NPI Number	:	1700909322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN BROKAW M.D.

Provider Business Mailing Address
First Line	:	5340 MIAMI RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45243-3920
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5340 MIAMI RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45243-3920
Country	:	US
Telephone Number	:	513-702-6877
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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