Healthcare Provider Details

I. General information

NPI: 1679567259
Provider Name (Legal Business Name): JEFFREY N BRODER MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 WEST AVE
NORTH AUGUSTA SC
29841-3350
US

IV. Provider business mailing address

1201 WEST AVE
NORTH AUGUSTA SC
29841-3350
US

V. Phone/Fax

Practice location:
  • Phone: 803-279-1030
  • Fax: 803-278-1344
Mailing address:
  • Phone: 803-279-1030
  • Fax: 803-278-1344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15157
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN459
License Number StateSC

VIII. Authorized Official

Name: JEFFREY N BRODER
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 803-279-1030