Provider Demographics
NPI:1376705848
Name:BROAD MIDWEST ANESTHESIA, LLC
Entity Type:Organization
Organization Name:BROAD MIDWEST ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:DROZDOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-838-2371
Mailing Address - Street 1:501 GLADES RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-1419
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:
Practice Address - Street 1:12345 W BEND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2182
Practice Address - Country:US
Practice Address - Phone:314-843-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC0897403207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty