Healthcare Provider Details

I. General information

NPI: 1144149592
Provider Name (Legal Business Name): BROADWAY MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CLIFTON AVE STE 1B
CLIFTON NJ
07013-3586
US

IV. Provider business mailing address

1 COLUMBUS PL
NEW YORK NY
10019-8201
US

V. Phone/Fax

Practice location:
  • Phone: 929-633-0990
  • Fax:
Mailing address:
  • Phone: 929-633-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN RUDDY FONDEUR SONI
Title or Position: PRESIDENT
Credential: MD
Phone: 929-633-0990