Basic Information
| Provider Information | |||||||||
| NPI: | 1164696464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 SPALDING DRIVE | ||||||||
| Address2: | STE 111 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605406766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305273788 | ||||||||
| FaxNumber: | 6306466071 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 SPALDING DRIVE | ||||||||
| Address2: | STE 111 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605406766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305273788 | ||||||||
| FaxNumber: | 6306466071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 04/02/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 036-115537 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2221474 | 01 | IL | BCBS | OTHER | 9919630 | 01 | IL | BCBS | OTHER | 1164696464-1 | 05 | IL | MEDICAID |