Provider Demographics
NPI:1821055492
Name:BRODARICK, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:BRODARICK
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 1:525 3RD ST STE 304
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3082
Mailing Address - Country:US
Mailing Address - Phone:503-783-6907
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE UNIT 406
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6258
Practice Address - Country:US
Practice Address - Phone:503-472-6131
Practice Address - Fax:503-434-9572
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0066849207RC0000X
MOR6974207RC0000X
ORMD208805207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO305031OtherGHP
MO218048OtherBCBS
MO200385417Medicaid
MO1366126OtherUHC
MO4415401OtherAETNA
MO1366126OtherUHC
MO218048OtherBCBS