Healthcare Provider Details

I. General information

NPI: 1902874928
Provider Name (Legal Business Name): TIMOTHY BRODERICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 02/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PIEDMONT AVE STE. 7000
CINCINNATI OH
45219-4231
US

IV. Provider business mailing address

2830 VICTORY PKWY STE. 320
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8787
  • Fax: 513-475-7348
Mailing address:
  • Phone: 513-245-3335
  • Fax: 513-475-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35-083461
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: