Provider Demographics
NPI:1033180930
Name:BROADWAY MEDICAL CENTER
Entity Type:Organization
Organization Name:BROADWAY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MYREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-762-6841
Mailing Address - Street 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN31T03BROtherBCBS
MN365838400Medicaid
MNC02166Medicare PIN