Healthcare Provider Details

I. General information

NPI: 1134243017
Provider Name (Legal Business Name): JENNIFER BROYLES MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 MAIN ST
KIMBALL TN
37347-5551
US

IV. Provider business mailing address

PO BOX 8487
CHATTANOOGA TN
37414-0487
US

V. Phone/Fax

Practice location:
  • Phone: 423-837-6000
  • Fax: 423-837-6009
Mailing address:
  • Phone: 423-899-2204
  • Fax: 423-698-4045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: JENNIFER BROYLES
Title or Position: PRESIDENT
Credential: MD
Phone: 423-837-6000