Provider Demographics
NPI:1538672399
Name:BROADWAY, ANTONIO DEMARCUS SR
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DEMARCUS
Last Name:BROADWAY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5810 MCCANN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-4149
Mailing Address - Country:US
Mailing Address - Phone:225-221-7831
Mailing Address - Fax:
Practice Address - Street 1:5810 MCCANN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-4149
Practice Address - Country:US
Practice Address - Phone:225-221-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000Medicaid