Provider Demographics
NPI:1649586314
Name:BROADWAY MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:BROADWAY MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-864-3456
Mailing Address - Street 1:6500 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3112
Mailing Address - Country:US
Mailing Address - Phone:201-864-3456
Mailing Address - Fax:201-869-7224
Practice Address - Street 1:6500 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3112
Practice Address - Country:US
Practice Address - Phone:201-864-3456
Practice Address - Fax:201-869-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty