Provider Demographics
NPI:1386984763
Name:BROADWAY COMMUNITY HEALTH CARE, INC
Entity type:Organization
Organization Name:BROADWAY COMMUNITY HEALTH CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:AIME
Authorized Official - Last Name:ERVILUS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, FNP-C, PMHNP-C
Authorized Official - Phone:856-365-1707
Mailing Address - Street 1:442 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1246
Mailing Address - Country:US
Mailing Address - Phone:856-365-1707
Mailing Address - Fax:856-365-1737
Practice Address - Street 1:442 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1246
Practice Address - Country:US
Practice Address - Phone:856-365-1707
Practice Address - Fax:856-365-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-22
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10322000261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care