Provider Demographics
NPI:1851380653
Name:BRODY, JEFFREY M (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:BRODY
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 1:125 METRO CENTER BLVD STE 2000
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1785
Mailing Address - Country:US
Mailing Address - Phone:401-432-2520
Mailing Address - Fax:401-453-8220
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5174
Practice Address - Fax:401-453-8220
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1548532085R0202X
RIMD081592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
007002783OtherHOSPITAL PIN
240090OtherRIH PILGRIM
240166OtherW AND I PILGRIM
720052301OtherCIGNA
CT003109685OtherMED ASSISTANCE
RI7002783OtherMEDICAL ASSISTANCE
004491OtherBLUECHIP
1600203OtherUNITED HEALTH PLANS
008159OtherBLUESHIELD
MA3198243Medicaid
000000001988OtherNHPRI
007056OtherTUFTS
3198243OtherHEALTHY START
8159OtherFEP BLUECROSS
240090OtherRIH PILGRIM
B61297Medicare UPIN
007002782Medicare ID - Type Unspecified