MEDICARE: 2013 BROADWAY EMERGENCY CARE 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	261QE0002X	Emergency Care Clinic/Center

General Provider Information

NPI Number	:	1770093643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2013 BROADWAY EMERGENCY CARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 93082
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-1082
Country	:	US
Telephone Number	:	817-421-0012
Fax Number	:	817-421-0036

Provider Business Practice Location Address
First Line	:	2015 BROADWAY ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78215-1117
Country	:	US
Telephone Number	:	817-421-0012
Fax Number	:	817-421-0036

Authorized Official
Title or Position	:	GENERAL COUNSEL
Name	:	JOHN B NEIMAN
Credential	:
Telephone Number	:	817-421-0034

Provider Enumeration Date	:	10/05/2017
Last Update Date	:	11/17/2017

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