Provider Demographics
NPI:1083646681
Name:BRODERICK, THOMAS F (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:F
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DO
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 905
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:802-748-4098
Practice Address - Street 1:195 INDUSTRIAL PKWY
Practice Address - Street 2:NVRH CORNER MEDICAL
Practice Address - City:LYNDON
Practice Address - State:VT
Practice Address - Zip Code:05849
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7599207P00000X
VT032-0000286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074951Medicaid
VT0005681Medicaid
NH3074951Medicaid
VTB85726Medicare UPIN