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General NPI Number Information
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NPI Number | 1508939976
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Entity Type | Individual
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Provider Name | JOHN SCOTT BRODERICK M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 06/08/2012
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Provider Practice Location Address
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Address Line | 13133 N PORT WASHINGTON RD SUITE G06
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City | MEQUON
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State | WI
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Zip | 53097-2419
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Country | US
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Telephone | 262-243-8371
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Fax | 262-243-8342
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Provider Business Mailing Address
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Address Line | 4425 N PORT WASHINGTON RD ATTN: CSMCP CLNIC CREDENTIALING
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City | GLENDALE
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State | WI
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Zip | 53212-1082
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Country | US
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Telephone | 262-243-8371
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Fax | 262-243-8342
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0600X
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Taxonomy Name | Clinical Neurophysiology Physician
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License Number | 46762-020
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License Number State | WI
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