Provider Demographics
NPI:1215905443
Name:GRODEN, BRIAN F (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:F
Last Name:GRODEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HAWTHORN ST # R
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02740-3429
Mailing Address - Country:US
Mailing Address - Phone:508-961-2403
Mailing Address - Fax:
Practice Address - Street 1:81 HAWTHORN ST # R
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-3429
Practice Address - Country:US
Practice Address - Phone:508-961-2403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA71961208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3074013Medicaid
MAJ10696Medicare ID - Type Unspecified
MA3074013Medicaid