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	208D00000X	General Practice Physician	15157	SC
2	207Q00000X	Family Medicine Physician	15157	SC
3	2083X0100X	Occupational Medicine 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	:	1992799563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY N BRODER MD

Provider Business Mailing 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

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	05/27/2010

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