Provider Demographics
NPI:1932314515
Name:BROADWAY MEDICAL P.C.
Entity Type:Organization
Organization Name:BROADWAY MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:VITOULIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-599-9355
Mailing Address - Street 1:120 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3233
Mailing Address - Country:US
Mailing Address - Phone:516-599-9355
Mailing Address - Fax:516-593-9355
Practice Address - Street 1:120 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3233
Practice Address - Country:US
Practice Address - Phone:516-599-9355
Practice Address - Fax:516-593-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002413111N00000X
NY205528204D00000X, 207Q00000X
NY017855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918905Medicaid
NY01918905Medicaid
NYH26750Medicare UPIN