Provider Demographics
NPI:1396722252
Name:BRODERICK, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:BRODERICK
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 1:237 WILLIAM HOWARD TAFT RD
Mailing Address - Street 2:2ND FLOOR, CBO2-3
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2610
Mailing Address - Country:US
Mailing Address - Phone:513-206-1060
Mailing Address - Fax:513-206-1062
Practice Address - Street 1:2123 AUBURN AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-206-1060
Practice Address - Fax:513-206-1062
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057828207RC0000X
IN01033468A207RC0000X
OH35.057828207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100387030Medicaid
57828-05OtherHUMANA
OH000000215162OtherANTHEM
OH284911OtherAMERIGROUP MEDICAID OH
OH311438871037OtherCARESOURCE MEDICAID OH
OH64862899Medicaid
OH0643141OtherAETNA
KY64862899Medicaid
25-20393OtherUNITED
OH000000215162OtherANTHEM
25-20393OtherUNITED
E02499Medicare UPIN
OH4098983Medicare PIN
060033892Medicare ID - Type UnspecifiedRAILROAD