Provider Demographics
NPI:1285718833
Name:BRODERICK, RICHARD WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
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 1:1435 N RANDALL RD STE 107
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2302
Mailing Address - Country:US
Mailing Address - Phone:224-359-0100
Mailing Address - Fax:
Practice Address - Street 1:1435 N RANDALL RD STE 107
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2302
Practice Address - Country:US
Practice Address - Phone:224-359-0130
Practice Address - Fax:224-359-0129
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0063270207T00000X
IL036099789207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000181241Medicaid
IL578500Medicare ID - Type Unspecified