MEDICARE: JEFFREY N BRODER MD

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	207Q00000X	Family Medicine Physician	15157	SC
2	207R00000X	Internal Medicine Physician	15157	SC
3	2080A0000X	Pediatric Adolescent Medicine Physician	15157	SC
4	2083P0901X	Public Health & General Preventive Medicine Physician	15157	SC
5	2083X0100X	Occupational Medicine Physician	15157	SC
6	261QP2300X	Primary Care Clinic/Center
7	363LF0000X	Family Nurse Practitioner	APN459	SC
8	208D00000X	General Practice Physician	15157	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871542332
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFREY N BRODER MD

Provider Business Mailing Address
First Line	:	PO BOX 724928
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31139-9028
Country	:	US
Telephone Number	:	678-838-1585
Fax Number	:	678-838-1587

Provider Business Practice Location Address
First Line	:	1201 WEST AVE
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-3350
Country	:	US
Telephone Number	:	803-279-1030
Fax Number	:	803-278-1344

Authorized Official
Title or Position	:	CEO
Name	:	DR. JEFFREY N BRODER
Credential	:	MD
Telephone Number	:	803-279-1030

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	07/11/2008

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