MEDICARE: BROADWAY VASCULAR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	25MA09187400	NJ
2	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1235539081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY VASCULAR LLC

Provider Business Mailing Address
First Line	:	106 APPLE ST STE 200A
Second Line	:
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-2670
Country	:	US
Telephone Number	:	732-475-0880
Fax Number	:	732-475-0881

Provider Business Practice Location Address
First Line	:	106 APPLE ST STE 200A
Second Line	:
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-2670
Country	:	US
Telephone Number	:	732-475-0880
Fax Number	:	732-475-0881

Authorized Official
Title or Position	:	OWNER
Name	:	DALLAS BROADWAY
Credential	:	MD
Telephone Number	:	917-780-8575

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	06/30/2022

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