Provider Demographics
NPI:1871253062
Name:BRIGHTLINE MEDICAL AFFILIATES, PA
Entity Type:Organization
Organization Name:BRIGHTLINE MEDICAL AFFILIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF PSYCHIATRY
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GRODBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-587-0024
Mailing Address - Street 1:400 CONCAR DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2681
Mailing Address - Country:US
Mailing Address - Phone:650-456-5777
Mailing Address - Fax:
Practice Address - Street 1:400 CONCAR DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2681
Practice Address - Country:US
Practice Address - Phone:650-456-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health