Basic Information
| Provider Information | |||||||||
| NPI: | 1760545784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROSE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ADOLPH | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | OHIO UNIVERSITY COLLEGE OF OSTEOPATHIC MEDICINE | ||||||||
| Address2: | 204 GROSVENOR HALL | ||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405939350 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY MEDICAL ASSOCIATES INC. | ||||||||
| Address2: | 2ND FLOOR PARKS HALL | ||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405932516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | 34003304B | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0487754 | 05 | OH | MEDICAID |