Provider Demographics
NPI:1578183653
Name:BROADBENT, REBECCA (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-364-4200
Mailing Address - Fax:314-364-6321
Practice Address - Street 1:200 CARR ST
Practice Address - Street 2:
Practice Address - City:PEA RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72751-2782
Practice Address - Country:US
Practice Address - Phone:479-488-6415
Practice Address - Fax:479-488-6416
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16094207P00000X
390200000X
ARE16094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program