MEDICARE: KELLY CLARK BRODERICK M.D.

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician	G78759	CA
2	2085R0202X	Diagnostic Radiology Physician	G78759	CA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	300121792	OTHER	CA	RAILROAD MEDICARE
4	300121755	OTHER	CA	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	00G787590	OTHER	CA	BLUE CROSS

NPI Number	:	1609821891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY CLARK BRODERICK M.D.

Provider Business Mailing Address
First Line	:	PO BOX 6102
Second Line	:
City	:	NOVATO
State	:	CA
Zip	:	94948-6102
Country	:	US
Telephone Number	:	415-884-3418
Fax Number	:	415-883-3406

Provider Business Practice Location Address
First Line	:	100 S SAN MATEO DR
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-3805
Country	:	US
Telephone Number	:	650-696-4515
Fax Number	:	650-696-4626

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

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	09/23/2020

100 S SAN MATEO DR , STE 400
SAN MATEO, CA
94401-3805

Practice Phone: 650-696-4101
Practice Fax: 650-696-4121