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NPI Code Detail

MEDICARE: BROAD STREET MEDICAL LLC

MEDICARE: BROAD STREET MEDICAL LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12086S0129XVascular Surgery Physician

General Provider Information

NPI Number : 1124670922
Entity Type Code : Organization
Provider Name (Legal Business Name) : BROAD STREET MEDICAL LLC
Provider Business Mailing Address
First Line : PO BOX 302
Second Line :
City : NORTHBROOK
State : IL
Zip : 60065-0302
Country : US
Telephone Number : 847-593-8460
Fax Number : 224-235-4652
Provider Business Practice Location Address
First Line : 2033 S BROAD ST STE B
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19148-5505
Country : US
Telephone Number : 215-809-1447
Fax Number : 224-235-4652
Authorized Official
Title or Position : CREDENTIALING MANAGER
Name : AMI ALMEDA
Credential :
Telephone Number : 224-318-0118
Provider Enumeration Date : 07/11/2019
Last Update Date : 07/11/2019

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Directions to “BROAD STREET MEDICAL LLC ” Practice Location

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