Individual
MR. JEROME DANIEL BRODERICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.T.
Contact information
Practice address
2911 KNAPP ST NE, SUITE C, GRAND RAPIDS, MI 49525-4600
(616) 975-9078
(616) 975-9248
Mailing address
2911 KNAPP ST NE, SUITE C, GRAND RAPIDS, MI 49525-4600
(616) 975-9078
(616) 975-9248
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
5501010335
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
650D113250
BLUE CROSS BLUE SHIELD ID
MI
01
—
JB010335
LISENCE NUMBER
MI
01
—
P33049F
BLUE CARE NETWORK ID
MI
Enumeration date
07/05/2005
Last updated
03/12/2012
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