Provider Demographics
NPI:1114084191
Name:BRODERICK, GENEVIEVE B (MD)
Entity Type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:B
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-472-6764
Mailing Address - Fax:617-770-9933
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE B1
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-472-6764
Practice Address - Fax:617-770-9933
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2015-06-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA2338832086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400210926Medicare PIN