Healthcare Provider Details

I. General information

NPI: 1467459958
Provider Name (Legal Business Name): PAUL EUGENE BRODERICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HADLEY RD STE 206
MOORESVILLE IN
46158-2905
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-834-1919
  • Fax: 317-834-1920
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number02001623A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: