Individual
DR. GARY BROADNAX
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1289 BROAD ST, AUGUSTA, GA 30901-1187
(706) 724-5557
(706) 724-5293
Mailing address
1289 BROAD STREET, AUGUSTA, GA 30901
(404) 688-9305
(404) 688-0621
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
586045874
PEACHSTATE HEALTH PLAN
GA
01
—
586045874
AETNA HEALTHCARE
—
01
—
G16213
SOUTH CAROLINA MEDICAID
SC
Enumeration date
12/06/2006
Last updated
11/12/2010
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