Provider Demographics
NPI:1306952858
Name:BROADWAY MEDICAL GROUP
Entity type:Organization
Organization Name:BROADWAY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:K.J.
Authorized Official - Middle Name:J
Authorized Official - Last Name:PHILIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-475-6063
Mailing Address - Street 1:4826 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3604
Mailing Address - Country:US
Mailing Address - Phone:773-275-8333
Mailing Address - Fax:773-275-9297
Practice Address - Street 1:4826 N. BROADWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-275-8333
Practice Address - Fax:773-275-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110420173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212244Medicare ID - Type Unspecified