Basic Information
| Provider Information | |||||||||
| NPI: | 1235152117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROAD | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 611 W BROWN ST | ||||||||
| Address2: | #101 | ||||||||
| City: | WYLIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724425287 | ||||||||
| FaxNumber: | 9724423181 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W BROWN ST | ||||||||
| Address2: | #101 | ||||||||
| City: | WYLIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724425287 | ||||||||
| FaxNumber: | 9724423181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1152490 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0021MG | 01 | BCBS GRP | OTHER | P00223957 | 01 | MEDICARE RAILROAD IND | OTHER | DD3715 | 01 | MEDICARE RAILROAD GRP | OTHER | 8T3999 | 01 | BCBS IND | OTHER |