Provider Demographics
NPI:1649245689
Name:BRODERMAN, SUSAN J (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:BRODERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2325 HERITAGE DRIVE SUITE 116
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925
Mailing Address - Country:US
Mailing Address - Phone:215-794-2462
Mailing Address - Fax:215-794-8496
Practice Address - Street 1:2325 HERITAGE DRIVE SUITE 116
Practice Address - Street 2:
Practice Address - City:FURLONG
Practice Address - State:PA
Practice Address - Zip Code:18925
Practice Address - Country:US
Practice Address - Phone:215-794-2462
Practice Address - Fax:215-794-8496
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034641E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001435061OtherBLUE SHIELD
007302OtherAETNA PPO MANAGED CARE
21198960001OtherKEYSTONE HEALTH EAST 65
21198960001OtherKEYSTONE LIAISON
2119896001OtherAMERIHEALTH HMO
PA0016680780002Medicaid
110243168OtherMULTIPLAN
2119896001OtherAMERIHEALTH ADMINISTRATOR
0001435061OtherPERSONAL CHOICE
21198960001OtherKEYSTONE HEALTH PLAN EAST
470888939OtherINTERCOUNTY
4708888939OtherDEVON
4708888939OtherFIRST HEALTH CCN
PHP185OtherOXFORD
007302OtherAETNA HMO
278863OtherMAMSI
1046905OtherKEYSTONE MERCY HEALTHPLAN
PC0139OtherHEALTH NET
21198960001OtherKEYSTONE LIAISON
PAF55376Medicare UPIN
110243168Medicare PIN