Basic Information
| Provider Information | |||||||||
| NPI: | 1851380653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 METRO CENTER BLVD STE 2000 | ||||||||
| Address2: | |||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028861785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014322520 | ||||||||
| FaxNumber: | 4014538220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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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 | 2085R0202X | 8159 | RI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD08159 | RI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000000001988 | 01 | NHPRI | OTHER | 004491 | 01 | BLUECHIP | OTHER | 007056 | 01 | TUFTS | OTHER | 1600203 | 01 | UNITED HEALTH PLANS | OTHER | 007002783 | 01 | HOSPITAL PIN | OTHER | 720052301 | 01 | CIGNA | OTHER | 8159 | 01 | FEP BLUECROSS | OTHER | 008159 | 01 | BLUESHIELD | OTHER | 240090 | 01 | RIH PILGRIM | OTHER | 7002783 | 01 | RI | MEDICAL ASSISTANCE | OTHER | 240166 | 01 | W AND I PILGRIM | OTHER | 3198243 | 01 | HEALTHY START | OTHER | 3198243 | 05 | MA | MEDICAID | 003109685 | 01 | CT | MED ASSISTANCE | OTHER |