MEDICARE: HEATH BROUSSARD MD

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	208600000X	Surgery Physician	31232	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801881958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATH BROUSSARD MD

Provider Business Mailing Address
First Line	:	PO BOX 400
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38302-0400
Country	:	US
Telephone Number	:	731-423-8697
Fax Number	:	731-422-5743

Provider Business Practice Location Address
First Line	:	700 W FOREST AVE
Second Line	:	STE 300
City	:	JACKSON
State	:	TN
Zip	:	38301-3937
Country	:	US
Telephone Number	:	731-422-0310
Fax Number	:	731-422-0440

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

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	11/29/2012

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Directions to “ HEATH BROUSSARD MD” Practice Location

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