Provider Demographics
NPI:1205032463
Name:WEST BROOKFIELD FAMILY PRACTICE
Entity Type:Organization
Organization Name:WEST BROOKFIELD FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BROZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-867-8977
Mailing Address - Street 1:46 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST BROOKFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01585-1044
Mailing Address - Country:US
Mailing Address - Phone:508-867-8977
Mailing Address - Fax:508-867-7361
Practice Address - Street 1:46 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST BROOKFIELD
Practice Address - State:MA
Practice Address - Zip Code:01585
Practice Address - Country:US
Practice Address - Phone:508-867-8977
Practice Address - Fax:508-867-7361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA219183OtherDR WILSON LICENSE
MA9787364Medicaid
MA73319OtherDR BROZ LICENSE
MA154490OtherDR JONES LICENSE
MA9787364Medicaid