Provider Demographics
NPI:1821033341
Name:BROOKHAVEN MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:BROOKHAVEN MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-217-3480
Mailing Address - Street 1:218 S VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-3234
Mailing Address - Country:US
Mailing Address - Phone:901-217-3480
Mailing Address - Fax:
Practice Address - Street 1:218 S VICTORIA AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-3234
Practice Address - Country:US
Practice Address - Phone:901-217-3480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124352Medicaid
MS=========OtherEIN
MS080003933Medicare ID - Type Unspecified
MSH39471Medicare UPIN