Provider Demographics
NPI:1114902541
Name:BROMBACH, JOSEPH A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:BROMBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3543 MOUNTAIN VIEW LN
Mailing Address - Street 2:
Mailing Address - City:BANEBERRY
Mailing Address - State:TN
Mailing Address - Zip Code:37890-4833
Mailing Address - Country:US
Mailing Address - Phone:865-674-0506
Mailing Address - Fax:865-397-8839
Practice Address - Street 1:555 E MEETING ST
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-5003
Practice Address - Country:US
Practice Address - Phone:865-674-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35295207Q00000X, 207R00000X, 207P00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3864832Medicaid
TN1509736Medicaid
VA1114902541Medicaid
KY7100137900Medicaid
3864832Medicare ID - Type Unspecified
TN1509736Medicaid
TN3864832Medicaid