Ian Matthew Broussard, D.O.
Emergency Medicine in Myrtle Beach, SC. Individual provider (NPI-1).
NPI number1871024968
StatusActive
Last updated in NPPESJun 12, 2017
Details
- NPI
- 1871024968
- Entity type
- Individual (NPI-1)
- Name
- Ian Matthew Broussard
- Credential
- D.O.
- Sex
- Male
- Sole proprietor
- Yes
- Enumeration date
- Mar 21, 2017
- Last updated
- Jun 12, 2017
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 207P00000X | Emergency Medicine | LL41064 | SC | Yes |
| 390200000X | Student in an Organized Health Care Education/Training Program | – | SC |
Practice location
809 82nd PkwyGrand Strand Medical Center Gme Office
Myrtle Beach, SC 29572-4607
Phone 843-692-1752 · Fax 843-692-1904
Mailing address
809 82nd PkwyGrand Strand Medical Center Gme Office
Myrtle Beach, SC 29572-4607
Phone 843-692-1752 · Fax 843-692-1904
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