Provider Demographics
NPI:1124099668
Name:BROADWAY, JOHN T (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:BROADWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:8890 CENTRE PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2170
Practice Address - Country:US
Practice Address - Phone:410-884-6000
Practice Address - Fax:410-884-9990
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24740225100000X
MD18673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
438M1009Medicare ID - Type Unspecified
S86206Medicare UPIN