MEDICARE: BROADWAY HEALTH GROUP 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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1831328855
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY HEALTH GROUP LLC

Provider Business Mailing Address
First Line	:	8121 BROADWAY ST
Second Line	:	STE 130
City	:	HOUSTON
State	:	TX
Zip	:	77061-1340
Country	:	US
Telephone Number	:	713-645-1300
Fax Number	:	713-645-1301

Provider Business Practice Location Address
First Line	:	8121 BROADWAY ST
Second Line	:	STE 130
City	:	HOUSTON
State	:	TX
Zip	:	77061-1340
Country	:	US
Telephone Number	:	713-645-1300
Fax Number	:	713-645-1301

Authorized Official
Title or Position	:	OWNER
Name	:	IAROSLAV MARYNYCH
Credential	:
Telephone Number	:	713-645-1300

Provider Enumeration Date	:	07/12/2009
Last Update Date	:	07/12/2009

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Directions to “BROADWAY HEALTH GROUP LLC ” Practice Location

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