Provider Demographics
NPI:1568780302
Name:SCOTT P. BRODY, M.D., PA
Entity Type:Organization
Organization Name:SCOTT P. BRODY, M.D., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:BRODY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-260-9808
Mailing Address - Street 1:11798 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1836
Mailing Address - Country:US
Mailing Address - Phone:904-260-9808
Mailing Address - Fax:904-260-2770
Practice Address - Street 1:11798 SAN JOSE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1836
Practice Address - Country:US
Practice Address - Phone:904-260-9808
Practice Address - Fax:904-260-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69231207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27848OtherBLUE CROSS AND BLUE SHIELD
FL378841500Medicaid
FLP00395604OtherRAILROAD MEDICARE