Provider Demographics
NPI:1598091100
Name:HERBERT E BROOKS MD PA
Entity Type:Organization
Organization Name:HERBERT E BROOKS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-547-4793
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:BONIFAY
Mailing Address - State:FL
Mailing Address - Zip Code:32425-0699
Mailing Address - Country:US
Mailing Address - Phone:850-547-4556
Mailing Address - Fax:850-547-4511
Practice Address - Street 1:2126 HIGHWAY 173
Practice Address - Street 2:
Practice Address - City:BONIFAY
Practice Address - State:FL
Practice Address - Zip Code:32425-5704
Practice Address - Country:US
Practice Address - Phone:850-547-4556
Practice Address - Fax:850-547-4511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME11075173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0011075OtherWC
FL30009OtherBCBS
FL043250400Medicaid
FLD62122Medicare UPIN
FL043250400Medicaid