Provider Demographics
NPI:1083696538
Name:BROADWAY FAMILY MEDICINE INC
Entity Type:Organization
Organization Name:BROADWAY FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:513-932-1936
Mailing Address - Street 1:PO BOX 4723
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4723
Mailing Address - Country:US
Mailing Address - Phone:513-932-1936
Mailing Address - Fax:513-932-3105
Practice Address - Street 1:1470 N BROADWAY ST
Practice Address - Street 2:SUITE100
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-1744
Practice Address - Country:US
Practice Address - Phone:513-932-1936
Practice Address - Fax:513-932-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCK5993OtherRR MCR
OH2378538Medicaid
OH9331191Medicare PIN