Healthcare Provider Details

I. General information

NPI: 1578625208
Provider Name (Legal Business Name): GEORGE STEVEN BRODERICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 VERULAM AVE
CINCINNATI OH
45213-2418
US

IV. Provider business mailing address

3024 PARKER RUN RD
NEW RICHMOND OH
45157-8101
US

V. Phone/Fax

Practice location:
  • Phone: 440-523-9966
  • Fax: 216-584-2895
Mailing address:
  • Phone: 513-553-0414
  • Fax: 513-553-0414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34007182
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34007182
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: