Provider Demographics
NPI:1396831053
Name:BRODERICK, JOHN P (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:174 CENTRAL STREET
Mailing Address - Street 2:SUITE 234
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852
Mailing Address - Country:US
Mailing Address - Phone:978-452-1466
Mailing Address - Fax:978-452-1826
Practice Address - Street 1:174 CENTRAL STREET
Practice Address - Street 2:SUITE 234
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-452-1466
Practice Address - Fax:978-452-1826
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2553111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA606350OtherCIGNA
MAY36807OtherBLUE CROSS/BLUE SHIELD
MA468952OtherTUFTS
MA63563OtherFALLON
MAPR1697Medicaid
MA351369OtherHARVARD PILGRIM
MA468952OtherTUFTS