Provider Demographics
NPI:1235152117
Name:BROAD, EDWARD RICHARD (MPT)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:RICHARD
Last Name:BROAD
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W BROWN ST
Mailing Address - Street 2:#101
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098
Mailing Address - Country:US
Mailing Address - Phone:972-442-5287
Mailing Address - Fax:972-442-3181
Practice Address - Street 1:611 W BROWN ST
Practice Address - Street 2:#101
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098
Practice Address - Country:US
Practice Address - Phone:972-442-5287
Practice Address - Fax:972-442-3181
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1152490225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0021MGOtherBCBS GRP
P00223957OtherMEDICARE RAILROAD IND
DD3715OtherMEDICARE RAILROAD GRP
8T3999OtherBCBS IND
00894YMedicare ID - Type UnspecifiedGRP
8T3999OtherBCBS IND
P00223957OtherMEDICARE RAILROAD IND