Provider Demographics
NPI:1720082316
Name:BROADWAY MEDICAL CLINIC LLP
Entity Type:Organization
Organization Name:BROADWAY MEDICAL CLINIC LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:503-331-7650
Mailing Address - Street 1:4212 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1460
Mailing Address - Country:US
Mailing Address - Phone:503-249-8787
Mailing Address - Fax:503-284-5168
Practice Address - Street 1:4212 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1460
Practice Address - Country:US
Practice Address - Phone:503-249-8787
Practice Address - Fax:503-284-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORG36720Medicare UPIN
ORC91487Medicare UPIN
ORG31512Medicare UPIN
ORG72620Medicare UPIN
ORI03438Medicare UPIN
ORF02278Medicare UPIN
ORF80334Medicare UPIN
ORG28943Medicare UPIN
ORC91764Medicare UPIN
ORF46212Medicare UPIN
ORF77463Medicare UPIN
ORI02371Medicare UPIN
ORF19966Medicare UPIN
ORE46705Medicare UPIN
ORH27483Medicare UPIN
ORE20615Medicare UPIN
ORE95149Medicare UPIN