Provider Demographics
NPI:1073586442
Name:BROUGH, SUSAN DOWD (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DOWD
Last Name:BROUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DANIELS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730
Mailing Address - Country:US
Mailing Address - Phone:781-538-5877
Mailing Address - Fax:
Practice Address - Street 1:295 VARNUM AVE
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-2134
Practice Address - Country:US
Practice Address - Phone:978-937-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219816207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2103567Medicaid
MAJ29622OtherBLUE SHIELD
MAI39311Medicare UPIN
MAJ29622OtherBLUE SHIELD