Provider Demographics
NPI:1063832822
Name:BROOKSIDE RADIOLOGY CONSULTANTS, INC.
Entity Type:Organization
Organization Name:BROOKSIDE RADIOLOGY CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC DACBR
Authorized Official - Phone:508-743-5691
Mailing Address - Street 1:62 BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-8315
Mailing Address - Country:US
Mailing Address - Phone:508-743-5691
Mailing Address - Fax:
Practice Address - Street 1:62 BROOKSIDE RD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-8315
Practice Address - Country:US
Practice Address - Phone:508-743-5691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACH2416111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45291OtherMEDICARE ID-TYPE UNSPECIFIED
MAU78594Medicare UPIN