Provider Demographics
NPI:1568971869
Name:BROAD REACH SPECIALTY SURGERY INC
Entity Type:Organization
Organization Name:BROAD REACH SPECIALTY SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HEWETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-387-4724
Mailing Address - Street 1:8117 WEST MANCHESTER AVE
Mailing Address - Street 2:STE 368
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293
Mailing Address - Country:US
Mailing Address - Phone:949-387-4724
Mailing Address - Fax:
Practice Address - Street 1:8117 WEST MANCHESTER AVE
Practice Address - Street 2:STE 368
Practice Address - City:PLAYA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90293
Practice Address - Country:US
Practice Address - Phone:949-387-4724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty