Provider Demographics
NPI:1376713925
Name:BRUNSWICK INTERNAL MEDICINE INC.
Entity Type:Organization
Organization Name:BRUNSWICK INTERNAL MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:MODIE
Authorized Official - Suffix:
Authorized Official - Credentials:CCS
Authorized Official - Phone:330-225-7733
Mailing Address - Street 1:3724 CENTER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-4439
Mailing Address - Country:US
Mailing Address - Phone:330-225-7733
Mailing Address - Fax:330-220-0902
Practice Address - Street 1:3724 CENTER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-4439
Practice Address - Country:US
Practice Address - Phone:330-225-7733
Practice Address - Fax:330-220-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0956292Medicaid
OH0956292Medicaid
OH0372890001Medicare NSC