Healthcare Provider Details

I. General information

NPI: 1982988903
Provider Name (Legal Business Name): BROADWAY MANHATTAN MEDICAL OFFICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2011
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 BROADWAY STE 1K
NEW YORK NY
10034-3119
US

IV. Provider business mailing address

4915 BROADWAY STE 1K
NEW YORK NY
10034-3119
US

V. Phone/Fax

Practice location:
  • Phone: 212-543-2500
  • Fax: 212-543-2503
Mailing address:
  • Phone: 212-543-2500
  • Fax: 212-543-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MURUGA RAJ
Title or Position: PHYSICIAN
Credential: M.D
Phone: 212-543-2500