Provider Demographics
NPI:1104830348
Name:BRODER, MICHAEL H (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:BRODER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1111
Mailing Address - Country:US
Mailing Address - Phone:334-269-0212
Mailing Address - Fax:334-269-2144
Practice Address - Street 1:2034 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1111
Practice Address - Country:US
Practice Address - Phone:334-269-0212
Practice Address - Fax:334-269-2144
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO313174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE63978Medicare UPIN