Basic Information
| Provider Information | |||||||||
| NPI: | 1285674499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROEREN | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 17055 RUBEN LN | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970559276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036688002 | ||||||||
| FaxNumber: | 5036685246 | ||||||||
| Practice Location | |||||||||
| Address1: | 17055 RUBEN LN | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970559276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036688002 | ||||||||
| FaxNumber: | 5036685246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 26866 | AL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | MD157517 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009933006 | 05 | AL | MEDICAID | 051529785 | 01 | AL | BLUE CROSS | OTHER | 009933004 | 05 | AL | MEDICAID | 009933007 | 05 | AL | MEDICAID | 051529786 | 01 | AL | BLUE CROSS | OTHER | 009933008 | 05 | AL | MEDICAID | 051529784 | 01 | AL | BLUE CROSS | OTHER | 051529787 | 01 | AL | BLUE CROSS | OTHER |