Provider Demographics
NPI:1396803797
Name:BROADWAY SPORTS AND INTERNAL MEDICINE
Entity type:Organization
Organization Name:BROADWAY SPORTS AND INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:SCHUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-215-2288
Mailing Address - Street 1:1600 116TH AVE NE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3014
Mailing Address - Country:US
Mailing Address - Phone:206-215-2288
Mailing Address - Fax:206-215-2289
Practice Address - Street 1:1600 116TH AVE NE
Practice Address - Street 2:SUITE 202
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3014
Practice Address - Country:US
Practice Address - Phone:206-215-2288
Practice Address - Fax:206-215-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0019545207QS0010X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD0019545OtherWA STATE LICENSE
WAG8898922Medicare PIN
WAA05585Medicare UPIN