Jerome Daniel Broderick, P.T.

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

5501010335 Issued in MI

Practice address

2911 Knapp St NE
Suite C
Grand Rapids, MI 49525-4600

Phone

(616) 975-9078

Fax

(616) 975-9248

NPI assigned

Jul 5, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 3

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1120521600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1331510400000",
    "number": "1881691962",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2911 KNAPP ST NE",
            "address_2": "SUITE C",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495254600",
            "telephone_number": "616-975-9078",
            "fax_number": "616-975-9248"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2911 KNAPP ST NE",
            "address_2": "SUITE C",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495254600",
            "telephone_number": "616-975-9078",
            "fax_number": "616-975-9248"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRODERICK",
        "first_name": "JEROME",
        "middle_name": "DANIEL",
        "name_prefix": "Mr.",
        "credential": "P.T.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-07-05",
        "last_updated": "2012-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MI",
            "license": "5501010335",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD ID",
            "identifier": "650D113250",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CARE NETWORK ID",
            "identifier": "P33049F",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LISENCE NUMBER",
            "identifier": "JB010335",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Megan Brock, LLMSW
• Tara Ann Brockman, MD
• Kaelee Sara Brockway, PT, DPT, GCS, CEEAA
• Danielle K Brodberg, AT, ATC
• Cassandra Broden
• Jacqueline Broders, PT, DPT
• Nicole Denice Broderson, MS, RD
• Beth Ann Brodnicki, MSPT, CMLDT
• Steven Eric Brodnicki, P.T.
• Mary B Broeckert, MD

• Physical Therapist in Grand Rapids, MI
• Providers in Grand Rapids, MI by specialty
• Physical Therapist in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.