1720478340 NPI number — MR. KEVIN ALAN BROUSSARD RPH ANP

Table of content: MR. KEVIN ALAN BROUSSARD RPH ANP (NPI 1720478340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720478340 NPI number — MR. KEVIN ALAN BROUSSARD RPH ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
KEVIN
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPH ANP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720478340
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2014 HIGHWAY 45 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39301-2735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-482-5799
Provider Business Mailing Address Fax Number:
601-485-5045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2014 HIGHWAY 45 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39301-2735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-482-5799
Provider Business Practice Location Address Fax Number:
601-485-5045
Provider Enumeration Date:
02/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  P-09013 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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