Basic Information
| Provider Information | |||||||||
| NPI: | 1578625208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 PARKER RUN RD | ||||||||
| Address2: | |||||||||
| City: | NEW RICHMOND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451578101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135530414 | ||||||||
| FaxNumber: | 5135530414 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 VERULAM AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452132418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405239966 | ||||||||
| FaxNumber: | 2165842895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 34007182 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 34007182 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1578625208 | 05 | WV | MEDICAID |