Provider Demographics
NPI:1598765943
Name:BRODELL, ROBERT T (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:BRODELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:UMMC-DEPARTMENT OF DERMATOLOGY
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-3374
Mailing Address - Fax:601-815-6613
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-3374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051453207N00000X, 207ND0900X
MS22119207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01087832OtherRAILROAD MEDICARE
MS08970301Medicaid
MS08970301Medicaid
OHA15988Medicare UPIN
OHBRO563641Medicare PIN
MS302I070980Medicare PIN
MS302I070982Medicare PIN
MS302I070980Medicare PIN