Provider Demographics
NPI:1861501561
Name:PETER H BROEKELSCHEN MD INC
Entity Type:Organization
Organization Name:PETER H BROEKELSCHEN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROEKELSCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-759-1042
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 607
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-759-1042
Mailing Address - Fax:949-759-0143
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 607
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-759-1042
Practice Address - Fax:949-759-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25076207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W21501Medicare PIN
A24275Medicare UPIN