Healthcare Provider Details

I. General information

NPI: 1073555348
Provider Name (Legal Business Name): KEVIN E BROYLES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 BELLEVIEW AVE SE EMERGENCY DEPT
ROANOKE VA
24014-1838
US

IV. Provider business mailing address

PO BOX 2080
KILMARNOCK VA
22482-2080
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax: 540-981-9550
Mailing address:
  • Phone: 804-435-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102201510
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: