Provider Demographics
NPI:1760493365
Name:BRODERICK-CANTWELL, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:BRODERICK-CANTWELL
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 1:600 SUN TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8643
Mailing Address - Country:US
Mailing Address - Phone:256-975-4291
Mailing Address - Fax:256-288-3334
Practice Address - Street 1:7101 US HIGHWAY 90 STE 103
Practice Address - Street 2:
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9510
Practice Address - Country:US
Practice Address - Phone:251-517-5800
Practice Address - Fax:256-429-9411
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL289502084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC28903OtherMEDICAL LICENSE
SCQ48343Medicaid
CO1353044Medicaid
CODR-35304OtherMEDICAL LICENSE
AL28950OtherMEDICAL LICENSE
AL28950OtherMEDICAL LICENSE
SC28903OtherMEDICAL LICENSE
SCQ48343Medicaid