Provider Demographics
NPI:1528568086
Name:BRODERICK, JAMES E JR
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:BRODERICK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 BURLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1406
Mailing Address - Country:US
Mailing Address - Phone:781-761-5089
Mailing Address - Fax:
Practice Address - Street 1:205 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1406
Practice Address - Country:US
Practice Address - Phone:781-761-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA99618201OtherNETWORK HEALTH
MA0000023532OtherBMC
MA1004745OtherNHP
MA1004745OtherFALLON
MA042611055OtherTAX ID
MA1303287OtherMBHP
MAM18633OtherBCBS