MEDICARE: BROADWAY 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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548370547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 149
Second Line	:
City	:	ABERDEEN
State	:	WA
Zip	:	98520-0063
Country	:	US
Telephone Number	:	360-538-7292
Fax Number	:	360-533-2566

Provider Business Practice Location Address
First Line	:	104 W 4TH ST
Second Line	:	SUITE # 105
City	:	ABERDEEN
State	:	WA
Zip	:	98520-3932
Country	:	US
Telephone Number	:	360-538-7292
Fax Number	:	360-533-2566

Authorized Official
Title or Position	:	FAMILY MEDICINE PHYICIAN CEO BROAWA
Name	:	DR. ANTOINE DOUGLASS JOHNSON
Credential	:	MD
Telephone Number	:	360-538-7292

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2020

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Directions to “BROADWAY CLINIC INC ” Practice Location

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