Provider Demographics
NPI:1598272999
Name:BRODERICK, BYRON (PTA)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2407
Mailing Address - Country:US
Mailing Address - Phone:773-687-9442
Mailing Address - Fax:
Practice Address - Street 1:1921 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2407
Practice Address - Country:US
Practice Address - Phone:773-687-9442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-07
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008003225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant