MEDICARE: MICHAEL SCOTT BROAD PA-C

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	363AS0400X	Surgical Physician Assistant	5601003846	MI

General Provider Information

NPI Number	:	1356380935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL SCOTT BROAD PA-C

Provider Business Mailing Address
First Line	:	1635 FAIRHOLME RD
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-2368
Country	:	US
Telephone Number	:	313-882-5473
Fax Number	:

Provider Business Practice Location Address
First Line	:	1555 SOUTH BLVD E
Second Line	:	SUITE 310
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48307-5605
Country	:	US
Telephone Number	:	248-215-8095
Fax Number	:	248-289-1086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	11/06/2012

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