1710097985 NPI number — DR. MARK BROADHEAD M.D.

Table of content: DR. MARK BROADHEAD M.D. (NPI 1710097985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710097985 NPI number — DR. MARK BROADHEAD M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROADHEAD
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1710097985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 W 2ND STREET
Provider Second Line Business Mailing Address:
227
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89503-5345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-784-1223
Provider Business Mailing Address Fax Number:
775-327-2006

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 W 2ND STREET
Provider Second Line Business Practice Location Address:
#216
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89503-5345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-784-6388
Provider Business Practice Location Address Fax Number:
775-784-1428
Provider Enumeration Date:
08/30/2006

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: 2084P0800X , with the licence number:  9565 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002016871 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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