Provider Demographics
NPI:1164696464
Name:BRODERICK, WILLIAM ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
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 1:120 SPALDING DRIVE
Mailing Address - Street 2:STE 111
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6766
Mailing Address - Country:US
Mailing Address - Phone:630-527-3788
Mailing Address - Fax:630-646-6071
Practice Address - Street 1:120 SPALDING DRIVE
Practice Address - Street 2:STE 111
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6766
Practice Address - Country:US
Practice Address - Phone:630-527-3788
Practice Address - Fax:630-646-6071
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115537207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2221474OtherBCBS
IL9919630OtherBCBS
IL1164696464-1Medicaid
IL399180002Medicare PIN
IL366700004Medicare PIN
ILP00775241Medicare PIN
IL215010012Medicare PIN