Provider Demographics
NPI:1356554992
Name:BROOKLINE VILLAGE OBGYN LLC
Entity type:Organization
Organization Name:BROOKLINE VILLAGE OBGYN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-735-8800
Mailing Address - Street 1:1 BROOKLINE PL
Mailing Address - Street 2:SUITE 521
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7224
Mailing Address - Country:US
Mailing Address - Phone:617-735-8800
Mailing Address - Fax:617-278-9358
Practice Address - Street 1:1 BROOKLINE PL
Practice Address - Street 2:SUITE 521
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7224
Practice Address - Country:US
Practice Address - Phone:617-735-8800
Practice Address - Fax:617-278-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21119Medicare ID - Type Unspecified