Basic Information
| Provider Information | |||||||||
| NPI: | 1396752424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUGH | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 DANIELS DR | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017301202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815385877 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | LOWELL GENERAL HOSPITAL | ||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 05/23/2008 | ||||||||
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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 | 207P00000X | 216298 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 0101057869 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2102412 | 05 | MA | MEDICAID | J29626 | 01 | MA | BLUE SHIELD | OTHER |