Provider Demographics
NPI:1992820435
Name:BROADWAY INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:BROADWAY INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECXTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ESREL
Authorized Official - Middle Name:A
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-278-3254
Mailing Address - Street 1:680 BROADWAY
Mailing Address - Street 2:5TH FLOOR SUITE # 502
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1524
Mailing Address - Country:US
Mailing Address - Phone:973-278-2877
Mailing Address - Fax:
Practice Address - Street 1:680 BROADWAY
Practice Address - Street 2:5TH FLOOR SUITE # 502
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1524
Practice Address - Country:US
Practice Address - Phone:973-278-2877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA42261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1109502Medicaid
NJ1109502Medicaid