Provider Demographics
NPI:1912366147
Name:NYC BROADWAY HEALTH LLC
Entity Type:Organization
Organization Name:NYC BROADWAY HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:DARRIO
Authorized Official - Last Name:BARAQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-376-6100
Mailing Address - Street 1:111 BROADWAY
Mailing Address - Street 2:SUITE 1303
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-1901
Mailing Address - Country:US
Mailing Address - Phone:914-376-6100
Mailing Address - Fax:914-470-5056
Practice Address - Street 1:111 BROADWAY
Practice Address - Street 2:SUITE 1303
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1901
Practice Address - Country:US
Practice Address - Phone:914-376-6100
Practice Address - Fax:914-470-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty