MEDICARE: VASTI BROADSTONE MD

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	21533	KY
2	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	01046145A	IN

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760420137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VASTI BROADSTONE MD

Provider Business Mailing Address
First Line	:	2019 STATE ST
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4921
Country	:	US
Telephone Number	:	812-949-5700
Fax Number	:	812-949-5979

Provider Business Practice Location Address
First Line	:	2019 STATE ST
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4921
Country	:	US
Telephone Number	:	812-949-5700
Fax Number	:	812-949-5979

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

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	12/08/2020

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