Provider Demographics
NPI:1508939976
Name:BRODERICK, JOHN SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SCOTT
Last Name:BRODERICK
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 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLNIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-243-8371
Mailing Address - Fax:262-243-8342
Practice Address - Street 1:13133 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE G06
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2419
Practice Address - Country:US
Practice Address - Phone:262-243-8371
Practice Address - Fax:262-243-8342
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46762-0202084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology