Provider Demographics
NPI:1073835807
Name:BROSE, JOHN M
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:BROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 CICERO DR
Mailing Address - Street 2:
Mailing Address - City:IRWIN
Mailing Address - State:PA
Mailing Address - Zip Code:15642-6517
Mailing Address - Country:US
Mailing Address - Phone:724-610-1583
Mailing Address - Fax:724-863-1256
Practice Address - Street 1:1012 CICERO DR
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-6517
Practice Address - Country:US
Practice Address - Phone:724-610-1583
Practice Address - Fax:724-863-1256
Is Sole Proprietor?:No
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00000060171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00000060OtherQRP