Provider Demographics
NPI:1518923945
Name:BRODERICK, JERALD R (DC)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:R
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-3404
Mailing Address - Country:US
Mailing Address - Phone:574-264-4151
Mailing Address - Fax:574-262-9891
Practice Address - Street 1:1424 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3404
Practice Address - Country:US
Practice Address - Phone:574-264-4151
Practice Address - Fax:574-262-9891
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112520AMedicaid
IN306OtherCOMMERCIAL/WC/AA
IN000000084724OtherBLUE CROSS/BLUE SHIELD
IN306OtherCOMMERCIAL/WC/AA
U29275Medicare UPIN