Provider Demographics
NPI:1457498438
Name:BROADWAY FOOT & ANKLE CLINIC, PC
Entity Type:Organization
Organization Name:BROADWAY FOOT & ANKLE CLINIC, PC
Other - Org Name:BROADWAY FOOT CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-648-2200
Mailing Address - Street 1:3508 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1821
Mailing Address - Country:US
Mailing Address - Phone:503-282-8777
Mailing Address - Fax:503-282-8853
Practice Address - Street 1:3508 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1821
Practice Address - Country:US
Practice Address - Phone:503-282-8777
Practice Address - Fax:503-282-8853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00179213ES0103X
ORDP00315213ES0103X
ORDP00244213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR6150080001Medicare NSC
ORR137392Medicare PIN