Provider Demographics
NPI:1578605044
Name:BROADWAY SURGICAL INSTITUTE, LLC
Entity Type:Organization
Organization Name:BROADWAY SURGICAL INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:P
Authorized Official - Last Name:HERSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-260-2827
Mailing Address - Street 1:1451 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2711
Mailing Address - Country:US
Mailing Address - Phone:602-298-2653
Mailing Address - Fax:602-298-2686
Practice Address - Street 1:1451 S BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1811
Practice Address - Country:US
Practice Address - Phone:310-260-2827
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF1894Medicare PIN