Provider Demographics
NPI:1194802678
Name:BRODERICK, RUTH M
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:M
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RINGWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07456-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1069 RINGWOOD AVE
Practice Address - Street 2:STE 211
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1408
Practice Address - Country:US
Practice Address - Phone:973-467-7976
Practice Address - Fax:973-467-7971
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA00619500OtherLICENSE#