Basic Information
| Provider Information | |||||||||
| NPI: | 1871609453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODEUR | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3262 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658083262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
| FaxNumber: | 4178817268 | ||||||||
| Practice Location | |||||||||
| Address1: | 3850 S NATIONAL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696170 | ||||||||
| FaxNumber: | 4172696992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | T2004016409 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2007029596 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 207057605 | 05 | MO | MEDICAID |