Healthcare Provider Details

I. General information

NPI: 1881131662
Provider Name (Legal Business Name): BROADWAY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 16TH ST SUITE 301
DENVER CO
80202-5026
US

IV. Provider business mailing address

403 16TH ST SUITE 301
DENVER CO
80202-5026
US

V. Phone/Fax

Practice location:
  • Phone: 720-598-9206
  • Fax:
Mailing address:
  • Phone: 720-598-9206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0058017
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY CARPENTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 954-868-1563