Basic Information
| Provider Information | |||||||||
| NPI: | 1124670922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROAD STREET MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 302 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Practice Location | |||||||||
| Address1: | 2033 S BROAD ST STE B | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191485505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158091447 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | ALMEDA | ||||||||
| AuthorizedOfficialFirstName: | AMI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2243180118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.