Provider Demographics
NPI:1437154606
Name:BRODERSON, STEPHANIE O (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:O
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:4405 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4187
Practice Address - Country:US
Practice Address - Phone:605-328-9000
Practice Address - Fax:605-328-9001
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5610682Medicaid
SDS8262Medicare PIN
SDG89743Medicare UPIN
SD080176923Medicare PIN