1649245689 NPI number — SUSAN J BRODERMAN MD

Table of content: SUSAN J BRODERMAN MD (NPI 1649245689)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649245689 NPI number — SUSAN J BRODERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODERMAN
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649245689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2325 HERITAGE DRIVE SUITE 116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FURLONG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-794-2462
Provider Business Mailing Address Fax Number:
215-794-8496

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 HERITAGE DRIVE SUITE 116
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FURLONG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-794-2462
Provider Business Practice Location Address Fax Number:
215-794-8496
Provider Enumeration Date:
02/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD034641E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001435061 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007302 . This is a "AETNA PPO MANAGED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21198960001 . This is a "KEYSTONE HEALTH EAST 65" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21198960001 . This is a "KEYSTONE LIAISON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2119896001 . This is a "AMERIHEALTH HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0016680780002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110243168 . This is a "MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2119896001 . This is a "AMERIHEALTH ADMINISTRATOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0001435061 . This is a "PERSONAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21198960001 . This is a "KEYSTONE HEALTH PLAN EAST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 470888939 . This is a "INTERCOUNTY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4708888939 . This is a "DEVON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4708888939 . This is a "FIRST HEALTH CCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHP185 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 007302 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 278863 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1046905 . This is a "KEYSTONE MERCY HEALTHPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: PC0139 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".




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