Provider Demographics
NPI:1548370547
Name:BROADWAY CLINIC INC
Entity type:Organization
Organization Name:BROADWAY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY MEDICINE PHYICIAN CEO BROAWA
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:DOUGLASS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-538-7292
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-0063
Mailing Address - Country:US
Mailing Address - Phone:360-538-7292
Mailing Address - Fax:360-533-2566
Practice Address - Street 1:104 W 4TH ST
Practice Address - Street 2:SUITE # 105
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-3932
Practice Address - Country:US
Practice Address - Phone:360-538-7292
Practice Address - Fax:360-533-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7109903Medicaid
WA7109903Medicaid