Provider Demographics
NPI:1487619854
Name:BRODKEY, JASON A (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:BRODKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5315 ELLIOTT DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8634
Mailing Address - Country:US
Mailing Address - Phone:734-434-4110
Mailing Address - Fax:734-528-0987
Practice Address - Street 1:5315 ELLIOTT DR
Practice Address - Street 2:SUITE 102
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8634
Practice Address - Country:US
Practice Address - Phone:734-434-4110
Practice Address - Fax:734-528-0987
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301069152207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG28376Medicare UPIN
MI0N52540Medicare ID - Type Unspecified