Basic Information
| Provider Information | |||||||||
| NPI: | 1194802678 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 OAKWOOD DR | ||||||||
| Address2: | |||||||||
| City: | RINGWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074562024 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1069 RINGWOOD AVE | ||||||||
| Address2: | STE 211 | ||||||||
| City: | HASKELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074201408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734677976 | ||||||||
| FaxNumber: | 9734677971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40QA00619500 | 01 | NJ | LICENSE# | OTHER |