Provider Demographics
NPI:1881874154
Name:MICHAEL J BROOM M.D., P.A.
Entity type:Organization
Organization Name:MICHAEL J BROOM M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADDMIN
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BYRNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-481-2244
Mailing Address - Street 1:PO BOX 568008
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32856-8008
Mailing Address - Country:US
Mailing Address - Phone:407-481-2244
Mailing Address - Fax:407-481-8160
Practice Address - Street 1:1405 S ORANGE AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2154
Practice Address - Country:US
Practice Address - Phone:407-481-2244
Practice Address - Fax:407-481-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0052975174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD16920Medicare UPIN
FLK0019Medicare PIN