Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | PS003069-L | PA |
Y | 103T00000X | Psychologist | PS003069-L | PA |
NPI | 1003031154 |
---|---|
Provider Name | Dr. Michael S. Broder |
First Address | Philadelphia, PA 19102-4223 |
Second Address | Philadelphia, PA 19102-4223 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 08/07/2007 |