Provider Demographics
NPI:1881574861
Name:BROADWAY PROCEDURE CENTER
Entity type:Organization
Organization Name:BROADWAY PROCEDURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MINCKLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-800-6330
Mailing Address - Street 1:4834 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3610
Mailing Address - Country:US
Mailing Address - Phone:520-800-6330
Mailing Address - Fax:
Practice Address - Street 1:4834 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3610
Practice Address - Country:US
Practice Address - Phone:520-800-6330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty