Provider Demographics
NPI:1740327543
Name:BROOKFIELD PREVENTIVE MEDICINE, LLC
Entity type:Organization
Organization Name:BROOKFIELD PREVENTIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:EUGENIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CORRIERO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:203-740-7500
Mailing Address - Street 1:300 FEDERAL RD
Mailing Address - Street 2:BUILDING 1, SUITE 100
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-2412
Mailing Address - Country:US
Mailing Address - Phone:203-740-7500
Mailing Address - Fax:
Practice Address - Street 1:300 FEDERAL RD
Practice Address - Street 2:BUILDING 1, SUITE 100
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2412
Practice Address - Country:US
Practice Address - Phone:203-740-7500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001466363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03487Medicare ID - Type Unspecified