Healthcare Provider Details

I. General information

NPI: 1235539081
Provider Name (Legal Business Name): BROADWAY VASCULAR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 APPLE ST STE 200A
TINTON FALLS NJ
07724-2670
US

IV. Provider business mailing address

106 APPLE ST STE 200A
TINTON FALLS NJ
07724-2670
US

V. Phone/Fax

Practice location:
  • Phone: 732-475-0880
  • Fax: 732-475-0881
Mailing address:
  • Phone: 732-475-0880
  • Fax: 732-475-0881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number25MA09187400
License Number StateNJ

VIII. Authorized Official

Name: DALLAS BROADWAY
Title or Position: OWNER
Credential: MD
Phone: 917-780-8575