Provider Demographics
NPI:1083139216
Name:BRODERICK, MICHAEL GERARD (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERARD
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10332 ABBOTSFORD DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1715
Mailing Address - Country:US
Mailing Address - Phone:813-541-9087
Mailing Address - Fax:
Practice Address - Street 1:17 EXECUTIVE PARK DR NE STE 680
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2227
Practice Address - Country:US
Practice Address - Phone:404-364-9551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist