Provider Demographics
NPI:1497051395
Name:RONALD L. BROADWATER SR. M.D.PA
Entity Type:Organization
Organization Name:RONALD L. BROADWATER SR. M.D.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BROADWATER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:443-281-8086
Mailing Address - Street 1:12 BRECON PL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-2343
Mailing Address - Country:US
Mailing Address - Phone:443-281-8086
Mailing Address - Fax:443-281-8117
Practice Address - Street 1:12 BRECON PL
Practice Address - Street 2:SUITE 400
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2343
Practice Address - Country:US
Practice Address - Phone:443-281-8086
Practice Address - Fax:443-281-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD15200261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care