Provider Demographics
NPI:1588235436
Name:BROADWAY VASCULAR PLLC
Entity Type:Organization
Organization Name:BROADWAY VASCULAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-465-7015
Mailing Address - Street 1:1010 NW LOOP 410 STE 100-B
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2220
Mailing Address - Country:US
Mailing Address - Phone:210-465-7015
Mailing Address - Fax:210-465-7014
Practice Address - Street 1:1010 NW LOOP 410 STE 100-B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2220
Practice Address - Country:US
Practice Address - Phone:210-465-7015
Practice Address - Fax:210-465-7014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty