Provider Demographics
NPI:1780612457
Name:HEALEY, BRENDA J (MD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:J
Last Name:HEALEY
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 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-265-3300
Mailing Address - Fax:315-261-6412
Practice Address - Street 1:50 LEROY ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1786
Practice Address - Country:US
Practice Address - Phone:315-265-3300
Practice Address - Fax:315-261-6412
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009944174400000X
VT042-0009944207Q00000X
NY28619207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN2147Medicaid
VT0VN2147Medicaid
VTSX3404Medicare PIN