Provider Demographics
NPI:1922192822
Name:BRADEN, KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:BRADEN
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:PO BOX 62
Mailing Address - Street 2:TURNPIKE STATION
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-0062
Mailing Address - Country:US
Mailing Address - Phone:508-334-8815
Mailing Address - Fax:508-334-5374
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-856-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA515012080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2097133Medicaid
MA2097133Medicaid
MABR J02543Medicare ID - Type Unspecified