Provider Demographics
NPI:1508828633
Name:BROADMOORE, ANDREW D (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:D
Last Name:BROADMOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:DAVIS
Other - Last Name:BROADWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46673208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0495960Medicaid
IA18118OtherMEDICARE GROUP NUMBER
IAI49671Medicare UPIN
IA18118OtherMEDICARE GROUP NUMBER