Healthcare Provider Details

I. General information

NPI: 1760493365
Provider Name (Legal Business Name): JOHN JOSEPH BRODERICK-CANTWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 02/05/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 US HIGHWAY 90 STE 103
DAPHNE AL
36526-9510
US

IV. Provider business mailing address

600 SUN TEMPLE DR
MADISON AL
35758-8643
US

V. Phone/Fax

Practice location:
  • Phone: 251-517-5800
  • Fax: 256-429-9411
Mailing address:
  • Phone: 256-975-4291
  • Fax: 256-288-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28950
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number28950
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: