Basic Information
| Provider Information | |||||||||
| NPI: | 1952446189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROADWAY INTERNAL MEDICINE ASSOCIATES P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167971234 | ||||||||
| FaxNumber: | 5167970190 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167971234 | ||||||||
| FaxNumber: | 5167970190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | MICELI | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 5167971234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.