MEDICARE: MELISSA A BROEDERS P.A.-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601004115	MI

General Provider Information

NPI Number	:	1083618425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA A BROEDERS P.A.-C

Provider Business Mailing Address
First Line	:	301 EXPLORER ST
Second Line	:
City	:	GWINN
State	:	MI
Zip	:	49841-2813
Country	:	US
Telephone Number	:	906-346-4924
Fax Number	:	906-346-6474

Provider Business Practice Location Address
First Line	:	1414 W FAIR AVE
Second Line	:	STE 201
City	:	MARQUETTE
State	:	MI
Zip	:	49855-5406
Country	:	US
Telephone Number	:	906-225-4500
Fax Number	:	906-225-3919

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	04/14/2021

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1811991250 — MARTHA J SHORT M.D.
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Directions to “ MELISSA A BROEDERS P.A.-C” Practice Location

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