Basic Information
| Provider Information | |||||||||
| NPI: | 1497721294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROMBERG | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64226 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103280008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16 S EUTAW ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103285408 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 02/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 213609 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 204F00000X | D71017 | MD | Y | Allopathic & Osteopathic Physicians | Transplant Surgery | 204F00000X | 213609 | NY | N | Allopathic & Osteopathic Physicians | Transplant Surgery |
ID Information
| ID | Type | State | Issuer | Description | 02094439 | 05 | NY | MEDICAID |