Provider Demographics
NPI:1689766271
Name:LARRY K. BROADWELL, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LARRY K. BROADWELL, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BROADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-0399
Mailing Address - Street 1:820 JORDAN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-221-0399
Mailing Address - Fax:318-221-1940
Practice Address - Street 1:820 JORDAN
Practice Address - Street 2:SUITE 201
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-221-0399
Practice Address - Fax:318-221-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13598207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty