Basic Information
| Provider Information | |||||||||
| NPI: | 1083646681 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 905 | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058190905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | 8027484098 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 INDUSTRIAL PKWY | ||||||||
| Address2: | NVRH CORNER MEDICAL | ||||||||
| City: | LYNDON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 7599 | NH | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 032-0000286 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3074951 | 05 | NH | MEDICAID | 0005681 | 05 | VT | MEDICAID |