Healthcare Provider Details

I. General information

NPI: 1780624031
Provider Name (Legal Business Name): BROADWAY FAMILY PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 N FRANKLIN BLVD 2ND FLOOR
PLEASANTVILLE NJ
08232-2547
US

IV. Provider business mailing address

22 NORTH FRANKLIN BLVD 2ND FLOOR
PLEASANTVILLE NJ
08232-2547
US

V. Phone/Fax

Practice location:
  • Phone: 609-272-0655
  • Fax: 609-272-9317
Mailing address:
  • Phone: 609-272-0655
  • Fax: 609-272-9317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. JON M. REGIS
Title or Position: PRESIDENT
Credential: MD
Phone: 609-272-0655