Basic Information
Provider Information | |||||||||
NPI: | 1720630650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROAD STREET PROFESSIONAL MEDICAL SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 A | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191485505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157953855 | ||||||||
FaxNumber: | 2242354652 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2019 | ||||||||
LastUpdateDate: | 07/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALMEDA | ||||||||
AuthorizedOfficialFirstName: | AMI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2243180118 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.