Provider Demographics
NPI:1801818810
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROTHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
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:2006-07-25
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0070886470002Medicaid
PA410040784OtherMEDICARE RAILROAD
PAOEG001090OtherHETRICK LICENCE
PA1942274691OtherHETRICK NPI
PA060638OtherPTAN
PA1466887OtherHIGHMARK MEDICAL
PA436660OtherHETRICK IND HIGHMARLK/VIS
PAT30428Medicare UPIN