MEDICARE: BROADWAY CONVALESCENT CENTER, L.P.

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	332BN1400X	Nursing Facility Supplies (DME)	120074	TX
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	120074	TX
3	314000000X	Skilled Nursing Facility	113793	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245267319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY CONVALESCENT CENTER, L.P.

Provider Business Mailing Address
First Line	:	200 DRYDEN ROAD, SUITE 2000
Second Line	:
City	:	DRESHER
State	:	PA
Zip	:	19025-1048
Country	:	US
Telephone Number	:	215-441-7700
Fax Number	:	215-441-4255

Provider Business Practice Location Address
First Line	:	1841 FLAMINGO
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78209
Country	:	US
Telephone Number	:	210-824-5324
Fax Number	:	210-824-5360

Authorized Official
Title or Position	:	PRESIDENT OF GENERAL PARTNER
Name	:	MR. PETER J LICARI
Credential	:
Telephone Number	:	215-441-7700

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	10/25/2007

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