Individual
DR. WALLACE BROADBENT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1535 GULL RD, MSB 015, KALAMAZOO, MI 49048-1650
(269) 226-6933
(269) 226-6949
Mailing address
1535 GULL RD, MSB 015, KALAMAZOO, MI 49048-1650
(269) 226-6933
(269) 226-6949
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
5101011784
MI
208D00000X
General Practice Physician
5101011784
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
114572856
—
MI
01
—
3123256-11
MEDICAID - THREE RIVERS
MI
01
—
700G560080
BCBS GROUP-THREE RIVERS HEALTH
MI
01
—
WB011784
BLUE CROSS BLUE SHIELD
MI
Enumeration date
05/12/2006
Last updated
02/10/2009
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