Basic Information
| Provider Information | |||||||||
| NPI: | 1578605044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROADWAY SURGICAL INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1451 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022982653 | ||||||||
| FaxNumber: | 6022982686 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 S BROADWAY STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904041811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3102602827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 01/10/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERSEL | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDER | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3102602827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.