Healthcare Provider Details

I. General information

NPI: 1689648248
Provider Name (Legal Business Name): WILLIAM G BRODERICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 JAGER CT
CINCINNATI OH
45230-4344
US

IV. Provider business mailing address

7400 JAGER CT
CINCINNATI OH
45230-4344
US

V. Phone/Fax

Practice location:
  • Phone: 513-232-8100
  • Fax: 513-232-3875
Mailing address:
  • Phone: 513-232-8100
  • Fax: 513-232-3875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35067029
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: