Provider Demographics
NPI:1326094335
Name:BROADDUS, SAMUEL B (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:B
Last Name:BROADDUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:81 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 2350
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2764
Mailing Address - Country:US
Mailing Address - Phone:207-373-6690
Mailing Address - Fax:207-373-6695
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2350
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2764
Practice Address - Country:US
Practice Address - Phone:207-373-6690
Practice Address - Fax:207-373-6695
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD11648208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME263730099Medicaid
NH30007671Medicaid
MEP00687956Medicare PIN
ME01555201Medicare PIN
GX4844Medicare PIN
B85658Medicare UPIN
NH30007671Medicaid