1871542332 NPI number — JEFFREY N BRODER MD

Table of content: (NPI 1871542332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871542332 NPI number — JEFFREY N BRODER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY N BRODER MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTH AUGUSTA URGENT CARE FAMILY & OCCUPATIONAL MEDICINE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871542332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 724928
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31139-9028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-838-1585
Provider Business Mailing Address Fax Number:
678-838-1587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 WEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH AUGUSTA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29841-3350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-279-1030
Provider Business Practice Location Address Fax Number:
803-278-1344
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRODER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
N
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
803-279-1030

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080A0000X , with the licence number: 15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083P0901X , with the licence number: 15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2083X0100X , with the licence number: 15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 15157 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APN459 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GP2905 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com