MEDICARE: JOHN BROUSSARD PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT781	FL

General Provider Information

NPI Number	:	1548462898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN BROUSSARD PT

Provider Business Mailing Address
First Line	:	4412 N DAVIS HWY
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-2756
Country	:	US
Telephone Number	:	850-430-4250
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 N DAVIS HWY
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32503-2756
Country	:	US
Telephone Number	:	850-430-4250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	06/20/2013

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Directions to “ JOHN BROUSSARD PT” Practice Location

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