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General NPI Number Information
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NPI Number | 1457498438
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Entity Type | Organization
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Legal Business Name | BROADWAY FOOT & ANKLE CLINIC, PC
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 08/07/2009
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Provider Practice Location Address
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Address Line | 3508 NE BROADWAY ST
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City | PORTLAND
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State | OR
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Zip | 97232-1821
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Country | US
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Telephone | 503-282-8777
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Fax | 503-282-8853
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Provider Business Mailing Address
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Address Line | 3508 NE BROADWAY ST
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City | PORTLAND
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State | OR
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Zip | 97232-1821
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Country | US
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Telephone | 503-282-8777
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Fax | 503-282-8853
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Authorized Official
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Title or Position | DPM
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Name | ELLIOT MICHAEL
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Credential | DPM
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Telephone | 503-648-2200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DP00315
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DP00244
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DP00179
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License Number State | OR
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