Basic Information
| Provider Information | |||||||||
| NPI: | 1629062153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADNEY | ||||||||
| FirstName: | MICHLENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1279 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709912200 | ||||||||
| FaxNumber: | 7709911341 | ||||||||
| Practice Location | |||||||||
| Address1: | 1279 HIGHWAY 54 W | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709912200 | ||||||||
| FaxNumber: | 7709911341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 10/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 055207 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 253338437B | 05 | GA | MEDICAID | 253338437A | 05 | GA | MEDICAID |