Provider Demographics
NPI:1013092212
Name:BRODKOHUTIAK&JAMALILTD
Entity Type:Organization
Organization Name:BRODKOHUTIAK&JAMALILTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TURTURICI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-565-7810
Mailing Address - Street 1:1098 W BALTIMORE PIKE
Mailing Address - Street 2:SUITR 3311
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5139
Mailing Address - Country:US
Mailing Address - Phone:610-565-7810
Mailing Address - Fax:610-565-0546
Practice Address - Street 1:1098 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 3311
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5139
Practice Address - Country:US
Practice Address - Phone:610-565-7810
Practice Address - Fax:610-565-0546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD011593E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty