Provider Demographics
NPI:1407804834
Name:BRODERICK, BETHANY A (MD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:A
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-370-1441
Mailing Address - Fax:518-395-9431
Practice Address - Street 1:1044 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12307-1508
Practice Address - Country:US
Practice Address - Phone:518-370-1441
Practice Address - Fax:518-395-9431
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239752208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02756527Medicaid
NY02995513Medicaid
NY331833Medicare Oscar/Certification
NY53099AMedicare PIN