Healthcare Provider Details

I. General information

NPI: 1396722252
Provider Name (Legal Business Name): THOMAS BRODERICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2123 AUBURN AVE SUITE 136
CINCINNATI OH
45219-2906
US

IV. Provider business mailing address

237 WILLIAM HOWARD TAFT RD 2ND FLOOR, CBO2-3
CINCINNATI OH
45219-2610
US

V. Phone/Fax

Practice location:
  • Phone: 513-206-1060
  • Fax: 513-206-1062
Mailing address:
  • Phone: 513-206-1060
  • Fax: 513-206-1062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35057828
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01033468A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35.057828
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: