Provider Demographics
NPI:1467459958
Name:BRODERICK, PAUL EUGENE (DO)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EUGENE
Last Name:BRODERICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1215 HADLEY RD STE 206
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2905
Practice Address - Country:US
Practice Address - Phone:317-834-1919
Practice Address - Fax:317-834-1920
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2023-04-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02001623A208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000095924OtherANTHEM
INMEDICAREOtherM400061013
IN200037350Medicaid