Healthcare Provider Details

I. General information

NPI: 1245737188
Provider Name (Legal Business Name): SAMUEL FITZGERALD BRODERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD # E4.300
DALLAS TX
75390-7208
US

IV. Provider business mailing address

6451 BRENTWOOD STAIR RD STE 200
FORT WORTH TX
76112-3200
US

V. Phone/Fax

Practice location:
  • Phone: 214-648-3022
  • Fax:
Mailing address:
  • Phone: 817-496-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1245737188
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA179942
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberT68740844
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT0728
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: