Provider Demographics
NPI:1497074249
Name:JAMES E. BRODERICK
Entity Type:Organization
Organization Name:JAMES E. BRODERICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRODERICKD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:585-394-4070
Mailing Address - Street 1:470 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1702
Mailing Address - Country:US
Mailing Address - Phone:585-394-4070
Mailing Address - Fax:585-394-8563
Practice Address - Street 1:470 S PEARL ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1702
Practice Address - Country:US
Practice Address - Phone:585-394-4070
Practice Address - Fax:585-394-8563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004540213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01158323Medicaid
NYT92375Medicare UPIN
NY01158323Medicaid