Healthcare Provider Details

I. General information

NPI: 1740277797
Provider Name (Legal Business Name): WILLIAM GEORGE BROADHURST PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 OLD NEW MILFORD RD SUITE 3E
BROOKFIELD CT
06804-2430
US

IV. Provider business mailing address

60 OLD NEW MILFORD RD SUITE 3E
BROOKFIELD CT
06804-2430
US

V. Phone/Fax

Practice location:
  • Phone: 203-775-6205
  • Fax: 203-775-2414
Mailing address:
  • Phone: 203-775-6205
  • Fax: 203-775-2414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001092
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: