Provider Demographics
NPI:1629196761
Name:BROADWAY MEDICAL CORPORATION, PC
Entity Type:Organization
Organization Name:BROADWAY MEDICAL CORPORATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADOLPHUS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-887-0900
Mailing Address - Street 1:3195 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1006
Mailing Address - Country:US
Mailing Address - Phone:219-887-0900
Mailing Address - Fax:219-884-0930
Practice Address - Street 1:3195 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1006
Practice Address - Country:US
Practice Address - Phone:219-887-0900
Practice Address - Fax:219-884-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010-36654174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty