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General NPI Number Information
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NPI Number | 1104010032
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Entity Type | Organization
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Legal Business Name | BROADWAY MEDICAL TREATMENT CENTER, LLC
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Dates
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Enumeration Date | 09/04/2007
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Last Update Date | 09/04/2007
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Provider Practice Location Address
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Address Line | 1053 S BROADWAY
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-4729
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Country | US
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Telephone | 401-438-5551
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Fax | 401-438-7272
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Provider Business Mailing Address
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Address Line | 1053 S BROADWAY
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-4729
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Country | US
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Telephone | 401-438-5551
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Fax | 401-438-7272
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Authorized Official
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Title or Position | PHYSICIAN / OWNER
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Name | DR. PETER GEORGE BRASSARD
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Credential | M.D.
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Telephone | 401-438-5551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | CMD 06972
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License Number State | RI
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