Provider Demographics
NPI:1871542332
Name:JEFFREY N BRODER MD
Entity type:Organization
Organization Name:JEFFREY N BRODER MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
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:PO BOX 724928
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31139-9028
Mailing Address - Country:US
Mailing Address - Phone:678-838-1585
Mailing Address - Fax:678-838-1587
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:2006-05-10
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15157207Q00000X, 207R00000X, 2080A0000X, 2083P0901X, 2083X0100X, 208D00000X
261QP2300X
SCAPN459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2905Medicaid
SCGP2905Medicaid
SC7058Medicare ID - Type UnspecifiedGROUP NUMBER