MEDICARE: BROADWAY MED GROUP, INC

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
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1164106175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY MED GROUP, INC

Provider Business Mailing Address
First Line	:	801 E BROADWAY STE A
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-4528
Country	:	US
Telephone Number	:	818-945-0050
Fax Number	:	818-937-9063

Provider Business Practice Location Address
First Line	:	801 E BROADWAY STE A
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91205-4528
Country	:	US
Telephone Number	:	818-945-0050
Fax Number	:	818-937-9063

Authorized Official
Title or Position	:	OWNER
Name	:	ROSS TARKHAN
Credential	:
Telephone Number	:	818-945-0050

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	02/05/2024

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