Healthcare Provider Details

I. General information

NPI: 1346209301
Provider Name (Legal Business Name): MICHAEL H BRODERDORF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 16TH AVE NW STE 106
ROCHESTER MN
55901-1853
US

IV. Provider business mailing address

401 16TH AVE NW STE 106
ROCHESTER MN
55901-1853
US

V. Phone/Fax

Practice location:
  • Phone: 507-258-4680
  • Fax:
Mailing address:
  • Phone: 507-258-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number38976
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number38976
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: