Provider Demographics
NPI:1699741348
Name:GERRARD-GOUGH, BRODIE (MD)
Entity type:Individual
Prefix:
First Name:BRODIE
Middle Name:
Last Name:GERRARD-GOUGH
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 1:1633 MEDICAL CENTER PT
Mailing Address - Street 2:233
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 S CASCADE AVE
Practice Address - Street 2:140
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1624
Practice Address - Country:US
Practice Address - Phone:719-538-2936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23946208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01239466Medicaid
CO01239466Medicaid
X7298Medicare ID - Type Unspecified