Basic Information
| Provider Information | |||||||||
| NPI: | 1629030341 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODIE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | ROGERS | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890195 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365471700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1126 N CHURCH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368321700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 18929 | NC | X | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | 18929 | NC | X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 4098065 | 01 | NC | AETNA PROVIDER NUMBER | OTHER | 21403 | 01 | NC | MEDCOST PROVIDER NUMBER | OTHER | 614 | 01 | NC | PARTNERS MEDICARE | OTHER | 8918562 | 05 | NC | MEDICAID | 18562 | 01 | NC | BCBS NC PROVIDER NUMBER | OTHER |