MEDICARE: MR. KASSIUS JAMES BROADUS

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1710751193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KASSIUS JAMES BROADUS

Provider Business Mailing Address
First Line	:	2457 FAIRVIEW AVE APT 3
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-4135
Country	:	US
Telephone Number	:	518-596-9206
Fax Number	:

Provider Business Practice Location Address
First Line	:	2457 FAIRVIEW AVE APT 3
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45219-4135
Country	:	US
Telephone Number	:	518-596-9206
Fax Number	:

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

Provider Enumeration Date	:	11/07/2023
Last Update Date	:	11/07/2023

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