Provider Demographics
NPI:1689648248
Name:BRODERICK, WILLIAM G (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 JAGER CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4344
Mailing Address - Country:US
Mailing Address - Phone:513-232-8100
Mailing Address - Fax:513-232-3875
Practice Address - Street 1:7400 JAGER CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4344
Practice Address - Country:US
Practice Address - Phone:513-232-8100
Practice Address - Fax:513-232-3875
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0197700Medicaid
OH1220714OtherUNITED HEALTHCARE
OH6702901OtherHUMANA
OH000000007575OtherANTHEM BC/BS
OH0668904OtherAETNA