Provider Demographics
NPI:1780624031
Name:BROADWAY FAMILY PRACTICE PC
Entity type:Organization
Organization Name:BROADWAY FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:REGIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-272-0655
Mailing Address - Street 1:22 NORTH FRANKLIN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-2547
Mailing Address - Country:US
Mailing Address - Phone:609-272-0655
Mailing Address - Fax:609-272-9317
Practice Address - Street 1:22 N FRANKLIN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232-2547
Practice Address - Country:US
Practice Address - Phone:609-272-0655
Practice Address - Fax:609-272-9317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5569605Medicaid
NJ5569605Medicaid