Healthcare Provider Details

I. General information

NPI: 1033278361
Provider Name (Legal Business Name): GARY BROADNAX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 BROAD ST
AUGUSTA GA
30901-1187
US

IV. Provider business mailing address

1289 BROAD STREET
AUGUSTA GA
30901
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-5557
  • Fax: 706-724-5293
Mailing address:
  • Phone: 404-688-9305
  • Fax: 404-688-0621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: