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General NPI Number Information
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NPI Number | 1235130717
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Entity Type | Individual
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Provider Name | BROUGHTON D JOLLEY MD
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Gender | Male
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Dates
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Enumeration Date | 08/09/2005
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Last Update Date | 04/12/2017
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Provider Practice Location Address
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Address Line | 135 W RAVINE RD SUITE 5-B
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City | KINGSPORT
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State | TN
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Zip | 37660-3847
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Country | US
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Telephone | 423-224-3460
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Fax | 423-224-3465
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Provider Business Mailing Address
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Address Line | PO BOX 535744
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City | ATLANTA
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State | GA
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Zip | 30353-5510
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Country | US
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Telephone | 844-294-5114
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Fax | 865-691-0843
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 21958
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License Number State | TN
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