Provider Demographics
NPI:1679567259
Name:JEFFREY N BRODER MD PC
Entity type:Organization
Organization Name:JEFFREY N BRODER MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRODER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-279-1030
Mailing Address - Street 1:1201 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3350
Mailing Address - Country:US
Mailing Address - Phone:803-279-1030
Mailing Address - Fax:803-278-1344
Practice Address - Street 1:1201 WEST AVE
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3350
Practice Address - Country:US
Practice Address - Phone:803-279-1030
Practice Address - Fax:803-278-1344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15157208D00000X
SCAPN459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2905Medicaid
SCGP2905Medicaid