Provider Demographics
NPI:1427566694
Name:BROADWAY FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:BROADWAY FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-568-7377
Mailing Address - Street 1:612 HWY 25 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63825-9566
Mailing Address - Country:US
Mailing Address - Phone:573-568-7377
Mailing Address - Fax:573-568-7320
Practice Address - Street 1:612 STATE HIGHWAY 25 S
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:63825-9566
Practice Address - Country:US
Practice Address - Phone:573-803-3995
Practice Address - Fax:573-803-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014044250363LF0000X
MO126560363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty