Provider Demographics
NPI:1427227768
Name:LEE S. BROADBENT, M.D. APC
Entity type:Organization
Organization Name:LEE S. BROADBENT, M.D. APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BROADBENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-752-7122
Mailing Address - Street 1:550 E 1400 N
Mailing Address - Street 2:SUITE D
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2406
Mailing Address - Country:US
Mailing Address - Phone:435-752-7122
Mailing Address - Fax:435-755-9579
Practice Address - Street 1:550 E 1400 N
Practice Address - Street 2:SUITE D
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2406
Practice Address - Country:US
Practice Address - Phone:435-752-7122
Practice Address - Fax:435-755-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT731556181205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528569442004Medicaid
UT528569442004Medicaid