Provider Demographics
NPI:1942250980
Name:BRODERICK, DENISE ANN (MD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:ANN
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 1:330 C PELHAM ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615
Mailing Address - Country:US
Mailing Address - Phone:864-720-1299
Mailing Address - Fax:864-720-1300
Practice Address - Street 1:330C PELHAM RD
Practice Address - Street 2:SUITE 101C
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-720-1299
Practice Address - Fax:864-720-1300
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18473207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC184730Medicaid
SCG78055Medicare UPIN
SCG780557951Medicare PIN
SC57-6007863138OtherBLUE CHOICE OF SC
SCG78055Medicare UPIN
SC5157605OtherAETNA
SCG780553640Medicare PIN