Provider Demographics
NPI:1932106416
Name:BROADWAY PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:BROADWAY PHYSICAL THERAPY, INC.
Other - Org Name:DBA PROCARE HOME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-887-2273
Mailing Address - Street 1:4950 BROADWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4605
Mailing Address - Country:US
Mailing Address - Phone:219-887-2273
Mailing Address - Fax:219-884-2848
Practice Address - Street 1:4950 BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4605
Practice Address - Country:US
Practice Address - Phone:219-887-2273
Practice Address - Fax:219-884-2848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN003042251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000236008OtherANTHEM BLUE CROSS BLUE SH
IN000000236008OtherANTHEM BLUE CROSS BLUE SH
IN157538Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER