Provider Demographics
NPI:1306337209
Name:BROADSTREET HEALTHCARE INC
Entity type:Organization
Organization Name:BROADSTREET HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARVEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-332-4600
Mailing Address - Street 1:395 DANFORTH AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1975
Mailing Address - Country:US
Mailing Address - Phone:201-332-4600
Mailing Address - Fax:201-332-4670
Practice Address - Street 1:395 DANFORTH AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-1975
Practice Address - Country:US
Practice Address - Phone:201-332-4600
Practice Address - Fax:201-332-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06755300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7807406Medicaid