Provider Demographics
NPI:1891880217
Name:BROADWAY FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:BROADWAY FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BENTREM
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:540-896-7061
Mailing Address - Street 1:P. O. BOX 6
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815
Mailing Address - Country:US
Mailing Address - Phone:540-896-7061
Mailing Address - Fax:540-896-7062
Practice Address - Street 1:12515 TIMBERWAY
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815
Practice Address - Country:US
Practice Address - Phone:540-896-7061
Practice Address - Fax:540-896-7062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054180207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5619734Medicaid
VAF15267Medicare UPIN
C04861Medicare PIN