Basic Information
| Provider Information | |||||||||
| NPI: | 1265470678 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROADWAY FOOT & ANKLE PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24963 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2063205340 | ||||||||
| Practice Location | |||||||||
| Address1: | 6625 W CREST VIEW LOOP SE | ||||||||
| Address2: | |||||||||
| City: | SNOQUALMIE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980658912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253965424 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | LICHTER | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 2063862800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 193384900 | 01 | WA | WASHINGTON LABOR & INDUSTRY | OTHER |