Provider Demographics
NPI:1174501498
Name:BRODEY, MITCHELL V (MD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:V
Last Name:BRODEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:POB STE 4K
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5784
Practice Address - Fax:315-492-5183
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY141878207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC58681Medicare UPIN
NY110144342Medicare PIN
NY55290UMedicare PIN