Basic Information
| Provider Information | |||||||||
| NPI: | 1710085147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROAD | ||||||||
| FirstName: | LOUIS | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 S 10TH ST | ||||||||
| Address2: | 480 MAIN BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558900 | ||||||||
| FaxNumber: | 2159555245 | ||||||||
| Practice Location | |||||||||
| Address1: | 132 S 10TH ST | ||||||||
| Address2: | 480 MAIN BUILDING | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558900 | ||||||||
| FaxNumber: | 2159555245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/22/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD016957E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0059855001 | 05 | PA | MEDICAID |