Provider Demographics
NPI:1972536886
Name:BROCCO-KISH, KAREN J (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:BROCCO-KISH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 SUBSTATION RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8356
Mailing Address - Country:US
Mailing Address - Phone:330-273-4752
Mailing Address - Fax:
Practice Address - Street 1:3511 CENTER RD
Practice Address - Street 2:SUITE EC
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-4426
Practice Address - Country:US
Practice Address - Phone:330-273-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2015-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-8185-B2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0362594Medicaid
OH3052744Medicaid
OHBR7269851Medicare ID - Type Unspecified
OH0445812Medicare PIN
OH3052744Medicaid