Provider Demographics
NPI:1851432967
Name:BROMBERG, FRED G (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:G
Last Name:BROMBERG
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 1:310 W 4TH ST
Mailing Address - Street 2:APT 1802
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2944
Mailing Address - Country:US
Mailing Address - Phone:336-448-1374
Mailing Address - Fax:
Practice Address - Street 1:WAKE FOREST BAPTIST MEDICAL CTR
Practice Address - Street 2:MEDICAL CENTER BLVD, CARE COORDINATION DEPT
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157
Practice Address - Country:US
Practice Address - Phone:336-716-7964
Practice Address - Fax:336-716-9338
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03626400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6503101Medicaid
403870Medicare ID - Type UnspecifiedINACTIVE
NJ6503101Medicaid