MEDICARE: BROADWAY FAMILY CLINIC 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
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	126560	MO
2	363LF0000X	Family Nurse Practitioner	2014044250	MO

General Provider Information

NPI Number	:	1427566694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY FAMILY CLINIC LLC

Provider Business Mailing Address
First Line	:	612 HWY 25 SOUTH
Second Line	:
City	:	BLOOMFIELD
State	:	MO
Zip	:	63825-9566
Country	:	US
Telephone Number	:	573-568-7377
Fax Number	:	573-568-7320

Provider Business Practice Location Address
First Line	:	612 STATE HIGHWAY 25 S
Second Line	:
City	:	BLOOMFIELD
State	:	MO
Zip	:	63825-9566
Country	:	US
Telephone Number	:	573-803-3995
Fax Number	:	573-803-5222

Authorized Official
Title or Position	:	OFFICE/BILLING SUPERVISOR
Name	:	MELISSA JARRELL
Credential	:
Telephone Number	:	573-568-7377

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	08/08/2023

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Directions to “BROADWAY FAMILY CLINIC LLC ” Practice Location

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