Provider Demographics
NPI:1033179239
Name:BRAMBLEBUSH PEDIATRICS LLP
Entity Type:Organization
Organization Name:BRAMBLEBUSH PEDIATRICS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GIANNINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-548-6969
Mailing Address - Street 1:15 BRAMBLEBUSH PARK
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2325
Mailing Address - Country:US
Mailing Address - Phone:508-548-6969
Mailing Address - Fax:508-540-2793
Practice Address - Street 1:15 BRAMBLEBUSH PARK
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2325
Practice Address - Country:US
Practice Address - Phone:508-548-6969
Practice Address - Fax:508-540-2793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15804OtherBLUE SHIELD
MA9777369Medicaid
MA9777369Medicaid