Provider Demographics
NPI:1164742557
Name:IAN D BRODIE MD F R C S INC
Entity Type:Organization
Organization Name:IAN D BRODIE MD F R C S INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD F R C S INC
Authorized Official - Phone:562-594-8635
Mailing Address - Street 1:911 ELECTRIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6315
Mailing Address - Country:US
Mailing Address - Phone:562-594-8635
Mailing Address - Fax:562-594-6009
Practice Address - Street 1:911 ELECTRIC AVENUE
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6315
Practice Address - Country:US
Practice Address - Phone:562-594-8635
Practice Address - Fax:562-594-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-08
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29773305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
A29773Medicare PIN