Provider Demographics
NPI:1518488501
Name:BRODERSEN, BRENDAN (DO)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:BRODERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 S 17TH ST STE 310
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502-3700
Mailing Address - Country:US
Mailing Address - Phone:402-483-8555
Mailing Address - Fax:402-483-8554
Practice Address - Street 1:2221 S 17TH ST STE 310
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-3700
Practice Address - Country:US
Practice Address - Phone:402-483-8555
Practice Address - Fax:402-483-8554
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26682084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470553011-00Medicaid