Provider Demographics
NPI:1326070905
Name:BRODSKY, IRWIN G (MD)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:G
Last Name:BRODSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:175 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9048
Practice Address - Country:US
Practice Address - Phone:207-396-7700
Practice Address - Fax:207-396-7701
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15924207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30208396Medicaid
ME323170099Medicaid
NH30208396Medicaid
MEMM9456Medicare PIN
E11750Medicare UPIN
MEMM945603Medicare PIN