Provider Demographics
NPI:1992048466
Name:BROADWAY COMPREHENSIVE VEIN CENTER P.C.
Entity type:Organization
Organization Name:BROADWAY COMPREHENSIVE VEIN CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-235-0147
Mailing Address - Street 1:171 GREAT NECK RD
Mailing Address - Street 2:APT 3E
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3302
Mailing Address - Country:US
Mailing Address - Phone:917-817-2802
Mailing Address - Fax:
Practice Address - Street 1:360 SPRINGFIELD AVE
Practice Address - Street 2:SUITE 302D
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-4608
Practice Address - Country:US
Practice Address - Phone:973-969-6400
Practice Address - Fax:609-949-5555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-02
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09187400261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology