Provider Demographics
NPI:1497708002
Name:BROADWAY IMAGING MEDICAL CENTER
Entity Type:Organization
Organization Name:BROADWAY IMAGING MEDICAL CENTER
Other - Org Name:BROADWAY IMAGING MEDICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOSAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-548-0022
Mailing Address - Street 1:140 NORTH GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206
Mailing Address - Country:US
Mailing Address - Phone:818-548-0022
Mailing Address - Fax:818-548-8385
Practice Address - Street 1:140 NORTH GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-548-0022
Practice Address - Fax:818-548-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71010207RM1200X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A710100Medicaid
CA00A710100Medicaid
TP084Medicare ID - Type Unspecified