Provider Demographics
NPI:1497788087
Name:GARY T BROTHERSON MD INC
Entity Type:Organization
Organization Name:GARY T BROTHERSON MD INC
Other - Org Name:NIAGARA EYE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMIN.
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:PISCITELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-455-8004
Mailing Address - Street 1:1801 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4938
Mailing Address - Country:US
Mailing Address - Phone:814-455-8004
Mailing Address - Fax:814-456-6054
Practice Address - Street 1:1801 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4938
Practice Address - Country:US
Practice Address - Phone:814-455-8004
Practice Address - Fax:814-456-6054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030604E207W00000X
PAOS010267L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071671OtherBROTHERSON
PA060638OtherPTAN
PA062849OtherFATICA
PA1011674140001Medicaid
PA1444836OtherHIGHMARK MEDICAL GTB/FAF
PA1932173754OtherBROTHERSON NPI
PAMD030604EOtherBROTHERSON LICENSE
PAOS010267LOtherFATICA LICENSE
PA0009730980001Medicaid
PA1821062662OtherFATICA NPI
PAB34959Medicare UPIN
PA1821062662OtherFATICA NPI