Healthcare Provider Details

I. General information

NPI: 1467457697
Provider Name (Legal Business Name): ELIZABETH BRODERICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 08/28/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MANHATTAN SQUARE
HAMPTON VA
23666
US

IV. Provider business mailing address

23 MANHATTAN SQUARE
HAMPTON VA
23666
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-0358
  • Fax: 757-595-6745
Mailing address:
  • Phone: 757-595-0358
  • Fax: 757-595-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101051725
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: