Healthcare Provider Details

I. General information

NPI: 1790776482
Provider Name (Legal Business Name): JEFFREY K. BROUSSARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 20TH ST SUITE 606
KNOXVILLE TN
37916
US

IV. Provider business mailing address

501 20TH ST SUITE 606
KNOXVILLE TN
37916-1809
US

V. Phone/Fax

Practice location:
  • Phone: 865-546-8040
  • Fax: 865-541-2787
Mailing address:
  • Phone: 865-546-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number27390
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: