Provider Demographics
NPI:1336246602
Name:PETER BROBERG, MD AND ASSOCIATES, PA
Entity Type:Organization
Organization Name:PETER BROBERG, MD AND ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-447-6096
Mailing Address - Street 1:4207 JAMES CASEY ST STE 305
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1193
Mailing Address - Country:US
Mailing Address - Phone:512-447-6096
Mailing Address - Fax:
Practice Address - Street 1:4207 JAMES CASEY ST STE 305
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1193
Practice Address - Country:US
Practice Address - Phone:512-447-6096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080183901Medicaid
TXCG5346OtherPALMETTO RR MEDICARE
TX00224NMedicare PIN