Provider Demographics
NPI:1336106426
Name:BROADWAY INTERNAL MEDICINE ASSOCIATES L.L.C.
Entity Type:Organization
Organization Name:BROADWAY INTERNAL MEDICINE ASSOCIATES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:VOGT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-442-0320
Mailing Address - Street 1:204 N KEENE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8102
Mailing Address - Country:US
Mailing Address - Phone:573-442-0320
Mailing Address - Fax:573-442-0421
Practice Address - Street 1:204 N KEENE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8102
Practice Address - Country:US
Practice Address - Phone:573-442-0320
Practice Address - Fax:573-442-0421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO503817504Medicaid
MO503817504Medicaid