Provider Demographics
NPI:1346209301
Name:BRODERDORF, MICHAEL H (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:BRODERDORF
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 1:401 16TH AVE NW STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-1853
Mailing Address - Country:US
Mailing Address - Phone:507-258-4680
Mailing Address - Fax:
Practice Address - Street 1:401 16TH AVE NW STE 106
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-1853
Practice Address - Country:US
Practice Address - Phone:507-258-4680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN389762083X0100X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB51754Medicare UPIN