Provider Demographics
NPI:1861443202
Name:BROADBENT, WALLACE (DO)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:BROADBENT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:MSB 015
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-226-6933
Mailing Address - Fax:269-226-6949
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:MSB 015
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-226-6933
Practice Address - Fax:269-226-6949
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011784207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3123256-11OtherMEDICAID - THREE RIVERS
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MIWB011784OtherBLUE CROSS BLUE SHIELD
MI114572856Medicaid
MIC96038036Medicare PIN
MI3123256-11OtherMEDICAID - THREE RIVERS
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MIF52248Medicare UPIN
MIWB011784OtherBLUE CROSS BLUE SHIELD
MI230015Medicare Oscar/Certification