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General NPI Number Information
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NPI Number | 1558163865
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Entity Type | Organization
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Legal Business Name | BROADSTONE NEUROLOGY GROUP LLC
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Dates
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Enumeration Date | 03/26/2025
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Last Update Date | 03/26/2025
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Provider Practice Location Address
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Address Line | 3050 POST OAK BLVD STE 510
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City | HOUSTON
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State | TX
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Zip | 77056-6512
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Country | US
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Telephone | 281-674-3092
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Fax |
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Provider Business Mailing Address
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Address Line | 3050 POST OAK BLVD STE 510
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City | HOUSTON
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State | TX
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Zip | 77056-6512
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Country | US
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Telephone | 281-674-3092
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MELISSA MANTOR
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Credential |
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Telephone | 561-254-8836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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