Basic Information
| Provider Information | |||||||||
| NPI: | 1467434241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROGNA | ||||||||
| FirstName: | CARLO | ||||||||
| MiddleName: | GENNARO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074746943 | ||||||||
| FaxNumber: | 2074746946 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE STE 114 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074746943 | ||||||||
| FaxNumber: | 2074746946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD07007 | RI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | EL211147 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 2069-7 | 01 | RI | RI BC&BS | OTHER | R002168 | 01 | RI | TRICARE | OTHER | 200114 | 01 | RI | RI BLUE CHIP | OTHER | 010007007RI01 | 01 | RI | ANTHEM | OTHER | 0R0237 | 01 | RI | HEALTHNET | OTHER | RI7007 | 01 | RI | STATE MEDICAL LICENSE | OTHER |