Provider Demographics
NPI:1134125271
Name:BRODERICK, GEORGE T (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:T
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 N MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1184
Mailing Address - Country:US
Mailing Address - Phone:937-832-2425
Mailing Address - Fax:937-832-9804
Practice Address - Street 1:9000 N MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1184
Practice Address - Country:US
Practice Address - Phone:937-832-2425
Practice Address - Fax:937-832-9804
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062694B207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0849863Medicaid
OH0849863Medicaid
OHBR0705161Medicare ID - Type Unspecified