Provider Demographics
NPI:1730116021
Name:BRODERICK, GEARIN ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:GEARIN
Middle Name:ELIZABETH
Last Name:BRODERICK
Suffix:
Gender:F
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:P.O. BOX 886
Mailing Address - Street 2:512 WEST BEACH CT.
Mailing Address - City:FOLLY BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29439-0886
Mailing Address - Country:US
Mailing Address - Phone:843-588-6660
Mailing Address - Fax:
Practice Address - Street 1:109 BEE ST.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401
Practice Address - Country:US
Practice Address - Phone:843-789-7345
Practice Address - Fax:843-805-5972
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC195390Medicaid
SC195390Medicaid