Provider Demographics
NPI:1043955396
Name:BROAD HEALTH OF NC PC
Entity Type:Organization
Organization Name:BROAD HEALTH OF NC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTORUFO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-455-2406
Mailing Address - Street 1:154 W 16TH ST # 6-110
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6201
Mailing Address - Country:US
Mailing Address - Phone:617-513-4838
Mailing Address - Fax:
Practice Address - Street 1:2626 GLENWOOD AVE STE 550
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-1370
Practice Address - Country:US
Practice Address - Phone:706-455-2406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty