Provider Demographics
NPI:1891903837
Name:BROADWAY PEDIATRICS M.D.P.C.
Entity Type:Organization
Organization Name:BROADWAY PEDIATRICS M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-740-3900
Mailing Address - Street 1:4250 BROADWAY
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3748
Mailing Address - Country:US
Mailing Address - Phone:212-740-3900
Mailing Address - Fax:212-740-8232
Practice Address - Street 1:4250 BROADWAY
Practice Address - Street 2:SUITE 1C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3748
Practice Address - Country:US
Practice Address - Phone:212-740-3900
Practice Address - Fax:212-740-8232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01620699Medicaid