Provider Demographics
NPI:1235539081
Name:BROADWAY VASCULAR LLC
Entity Type:Organization
Organization Name:BROADWAY VASCULAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-780-8575
Mailing Address - Street 1:106 APPLE ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2670
Mailing Address - Country:US
Mailing Address - Phone:732-475-0880
Mailing Address - Fax:732-475-0881
Practice Address - Street 1:106 APPLE ST STE 200A
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-2670
Practice Address - Country:US
Practice Address - Phone:732-475-0880
Practice Address - Fax:732-475-0881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2085R0204X
NJ25MA09187400261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Single Specialty