Basic Information
| Provider Information | |||||||||
| NPI: | 1699934828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S WOODS MILL RD | ||||||||
| Address2: | 550N | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144343049 | ||||||||
| FaxNumber: | 3142056916 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 S WOODS MILL RD | ||||||||
| Address2: | 550N | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630173625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144343049 | ||||||||
| FaxNumber: | 3142056916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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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 | 208600000X | 2012013459 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 2012013459 | MO | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.