MEDICARE: BROADWAY MEDICAL 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	2085R0202X	Diagnostic Radiology Physician
2	2084N0400X	Neurology Physician	0058017	CO

General Provider Information

NPI Number	:	1881131662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	403 16TH ST
Second Line	:	SUITE 301
City	:	DENVER
State	:	CO
Zip	:	80202-5026
Country	:	US
Telephone Number	:	720-598-9206
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 16TH ST
Second Line	:	SUITE 301
City	:	DENVER
State	:	CO
Zip	:	80202-5026
Country	:	US
Telephone Number	:	720-598-9206
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TAMMY CARPENTER
Credential	:
Telephone Number	:	954-868-1563

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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