Healthcare Provider Details

I. General information

NPI: 1215215546
Provider Name (Legal Business Name): MIRANDA MARGUERITE BROADNEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 LINDEN AVE
BALTIMORE MD
21201-4606
US

IV. Provider business mailing address

737 W LOMBARD ST RM 323
BALTIMORE MD
21201-1009
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-8780
  • Fax: 410-225-8766
Mailing address:
  • Phone: 410-706-1196
  • Fax: 410-706-5103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberD77689
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR72561
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: