Provider Demographics
NPI:1528233988
Name:HARNISCH, BROOKE ASHLEY (MD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ASHLEY
Last Name:HARNISCH
Suffix:
Gender:F
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:UCONN MEDICAL GROUP
Mailing Address - Street 2:263 FARMINGTON AVENUE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-0001
Mailing Address - Country:US
Mailing Address - Phone:860-679-4100
Mailing Address - Fax:860-679-1064
Practice Address - Street 1:UCONN MEDICAL GROUP
Practice Address - Street 2:263 FARMINGTON AVENUE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-4100
Practice Address - Fax:860-679-1064
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA232874208800000X
WI60198208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528233988Medicaid
WI1528233988Medicaid
WI68086 2702Medicare PIN