| Broadway Medical Clinic | |
|
1351 Broadway El Cajon CA 92021-5811 | |
| (619) 383-6703 | |
| (866) 473-3324 |
| Full Name | Broadway Medical Clinic |
|---|---|
| Speciality | Internal Medicine |
| Location | 1351 Broadway, El Cajon, California |
| Authorized Official Name and Position | Jimi Ola Benson (PRESIDENT) |
| Authorized Official Contact | 3014661078 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Broadway Medical Clinic 1351 Broadway El Cajon CA 92021-5811 Ph: (619) 383-6703 | Broadway Medical Clinic 1351 Broadway El Cajon CA 92021-5811 Ph: (619) 383-6703 |
| NPI Number | 1275936270 |
|---|---|
| Provider Enumeration Date | 10/03/2014 |
| Last Update Date | 02/07/2022 |
| Certification Date | 02/07/2022 |
| Medicare PECOS PAC ID | 3173845005 |
|---|---|
| Medicare Enrollment ID | O20141204001162 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275936270 | NPI | - | NPPES |
| 1275936270 | Medicaid | CA | |
| 1477751667 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | A116611 (California) | Primary |
| Provider Name | Jimi O Benson |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1477751667 PECOS PAC ID: 7315111408 Enrollment ID: I20111130000256 |
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