Healthcare Provider Details

I. General information

NPI: 1740103993
Provider Name (Legal Business Name): MAXWELL R BROADUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E HAWTHORN PKWY STE 235
VERNON HILLS IL
60061-1454
US

IV. Provider business mailing address

175 E HAWTHORN PKWY STE 235
VERNON HILLS IL
60061-1454
US

V. Phone/Fax

Practice location:
  • Phone: 877-893-5544
  • Fax: 877-428-7891
Mailing address:
  • Phone: 877-893-5544
  • Fax: 877-428-7891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number150113145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: