MEDICARE: DR. TARA L BROADWATER MD

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	207Q00000X	Family Medicine Physician	40655	MN
2	2084P0800X	Psychiatry Physician	40655	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
9	P00138242	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	388R8BU	OTHER	MN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	NA2951032151	OTHER	MN	PREFFERED ONE
4	HP36174	OTHER	MN	HEALTH PARTNERS
5	1965380	OTHER	MN	AMERICAS PPO
6	124673	OTHER	MN	UCARE
7	41084933956001C212	OTHER		CHAMPUS
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255310298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA L BROADWATER MD

Provider Business Mailing Address
First Line	:	898 WESCOTT TRL APT 311
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-2272
Country	:	US
Telephone Number	:	507-304-1899
Fax Number	:

Provider Business Practice Location Address
First Line	:	898 WESCOTT TRL APT 311
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-2272
Country	:	US
Telephone Number	:	507-304-1899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	04/26/2023

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