Provider Demographics
NPI:1295830990
Name:BROADWAY MEDICAL CLINIC, P.A.
Entity Type:Organization
Organization Name:BROADWAY MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:J. FELIPE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-641-5656
Mailing Address - Street 1:3208 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77017-2321
Mailing Address - Country:US
Mailing Address - Phone:713-641-5656
Mailing Address - Fax:713-641-5293
Practice Address - Street 1:3208 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77017-2321
Practice Address - Country:US
Practice Address - Phone:713-641-5656
Practice Address - Fax:713-641-5293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7365261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092059701Medicaid
TX900013387001OtherAPS HEALTHCARE
TX10004520OtherAMERIGROUP
TX10020679OtherAMERIGROUP
TX000000U92MOtherBC BS
TX092059702Medicaid
TX133829501Medicaid
TX000000U92MOtherBC BS
TX092059702Medicaid
TX092059701Medicaid