Provider Demographics
NPI:1881691962
Name:BRODERICK, JEROME DANIEL (PT)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:DANIEL
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 KNAPP ST NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-4600
Mailing Address - Country:US
Mailing Address - Phone:616-975-9078
Mailing Address - Fax:616-975-9248
Practice Address - Street 1:2911 KNAPP ST NE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4600
Practice Address - Country:US
Practice Address - Phone:616-975-9078
Practice Address - Fax:616-975-9248
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D113250OtherBLUE CROSS BLUE SHIELD ID
MIP33049FOtherBLUE CARE NETWORK ID
MIJB010335OtherLISENCE NUMBER
MI0N81330Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
MIP33049FOtherBLUE CARE NETWORK ID
MIJB010335OtherLISENCE NUMBER
MIN81330002Medicare UPIN