Basic Information
| Provider Information | |||||||||
| NPI: | 1871542332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEFFREY N BRODER MD | ||||||||
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| OtherOrganizationName: | NORTH AUGUSTA URGENT CARE FAMILY & OCCUPATIONAL MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 724928 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311399028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788381585 | ||||||||
| FaxNumber: | 6788381587 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 WEST AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH AUGUSTA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298413350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032791030 | ||||||||
| FaxNumber: | 8032781344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 07/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRODER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8032791030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 15157 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 15157 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2080A0000X | 15157 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2083P0901X | 15157 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 2083X0100X | 15157 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 363LF0000X | APN459 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 208D00000X | 15157 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | GP2905 | 05 | SC | MEDICAID |