Provider Demographics
NPI:1629062153
Name:BROADNEY, MICHLENE (MD)
Entity Type:Individual
Prefix:
First Name:MICHLENE
Middle Name:
Last Name:BROADNEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 220
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4552
Mailing Address - Country:US
Mailing Address - Phone:770-991-2200
Mailing Address - Fax:770-991-1341
Practice Address - Street 1:1279 HIGHWAY 54 W
Practice Address - Street 2:SUITE 220
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4552
Practice Address - Country:US
Practice Address - Phone:770-991-2200
Practice Address - Fax:770-991-1341
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055207207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA253338437BMedicaid
GA253338437AMedicaid
GA16BBCRPMedicare ID - Type Unspecified
GAI28210Medicare UPIN