MEDICARE: NORTH BROADWAY MEDICAL CLINIC 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	207R00000X	Internal Medicine Physician	A25805	CA

General Provider Information

NPI Number	:	1356469381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH BROADWAY MEDICAL CLINIC INC

Provider Business Mailing Address
First Line	:	2926 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2601
Country	:	US
Telephone Number	:	323-221-1131
Fax Number	:	323-221-3197

Provider Business Practice Location Address
First Line	:	2926 N BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-2601
Country	:	US
Telephone Number	:	323-221-1131
Fax Number	:	323-221-3197

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FRANCISCO B. FUSCALDO
Credential	:	M.D.
Telephone Number	:	323-221-1131

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	08/05/2015

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