Provider Demographics
NPI:1053715284
Name:BROADNAX, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8063 MADISON AVE # 246
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6001
Mailing Address - Country:US
Mailing Address - Phone:317-750-0435
Mailing Address - Fax:
Practice Address - Street 1:8063 MADISON AVE # 246
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6001
Practice Address - Country:US
Practice Address - Phone:317-750-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201132640 AMedicaid