Provider Demographics
NPI:1104010032
Name:BROADWAY MEDICAL TREATMENT CENTER, LLC
Entity Type:Organization
Organization Name:BROADWAY MEDICAL TREATMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:BRASSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-438-5551
Mailing Address - Street 1:1053 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-4729
Mailing Address - Country:US
Mailing Address - Phone:401-438-5551
Mailing Address - Fax:401-438-7272
Practice Address - Street 1:1053 S BROADWAY
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-4729
Practice Address - Country:US
Practice Address - Phone:401-438-5551
Practice Address - Fax:401-438-7272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICMD 06972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty