1124265848 NPI number — BROADWAY INTERNAL MEDICINE P.C

Table of content: (NPI 1124265848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124265848 NPI number — BROADWAY INTERNAL MEDICINE P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY INTERNAL MEDICINE P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1124265848
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7517 41ST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMHURST
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11373-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-803-6300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7517 41ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-803-6300
Provider Business Practice Location Address Fax Number:
718-803-0085
Provider Enumeration Date:
01/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
MANUEL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
718-803-6300

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  156591 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1437162024 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com