Basic Information
| Provider Information | |||||||||
| NPI: | 1346237666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIODY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D., SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1866 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543051866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 2820 ROOSEVELT RD | ||||||||
| Address2: | |||||||||
| City: | MARINETTE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541433834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7157355225 | ||||||||
| FaxNumber: | 7157355388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 24359020 | WI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 160052937 | 01 | RR MEDICARE | OTHER | 30445700 | 05 | WI | MEDICAID |