1033278361 NPI number — DR. GARY BROADNAX MD

Table of content: DR. GARY BROADNAX MD (NPI 1033278361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033278361 NPI number — DR. GARY BROADNAX MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADNAX
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033278361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1289 BROAD STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-688-9305
Provider Business Mailing Address Fax Number:
404-688-0621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1289 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30901-1187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-724-5557
Provider Business Practice Location Address Fax Number:
706-724-5293
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 586045874 . This is a "PEACHSTATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "BCBS OF GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "AMERIGROUP COMMUNITY CARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "AETNA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 586045874 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: G16213 . This is a "SOUTH CAROLINA MEDICAID" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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