Provider Demographics
NPI:1699007963
Name:CENTRAL BROADWAY MEDICAL PC
Entity Type:Organization
Organization Name:CENTRAL BROADWAY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:AVELLINI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:8663-354-0404
Mailing Address - Street 1:364 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1619
Mailing Address - Country:US
Mailing Address - Phone:866-335-4040
Mailing Address - Fax:732-301-8222
Practice Address - Street 1:770 BROADWAY FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9557
Practice Address - Country:US
Practice Address - Phone:866-335-4040
Practice Address - Fax:732-301-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148049208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty