Provider Demographics
NPI:1346237666
Name:BRIODY, JOHN P (MD, SC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:BRIODY
Suffix:
Gender:M
Credentials:MD, SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2820 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3834
Practice Address - Country:US
Practice Address - Phone:715-735-5225
Practice Address - Fax:715-735-5388
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24359020207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160052937OtherRR MEDICARE
WI30445700Medicaid
B44805Medicare UPIN
WI001740115Medicare ID - Type Unspecified
160052937OtherRR MEDICARE