Basic Information
| Provider Information | |||||||||
| NPI: | 1841553088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADBENT | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | AARON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2537614201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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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 | 2085N0700X | MD188795 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 2017008637 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60837429 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD188795 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | MD60837429 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 0389197 | 01 | WA | LNI-TRA KING COUNTY | OTHER | 500744919 | 05 | OR | MEDICAID | 0389196 | 01 | WA | LNI-TRA REST OF WA | OTHER | 2097736 | 05 | WA | MEDICAID | 0389198 | 01 | WA | LNI-UAOM | OTHER | 0389199 | 01 | WA | LNI-DINW | OTHER |