Provider Demographics
NPI:1790734788
Name:BROUGHTON, RAYMOND NMN (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:NMN
Last Name:BROUGHTON
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:PO BOX 769
Mailing Address - Street 2:
Mailing Address - City:BAYOU LA BATRE
Mailing Address - State:AL
Mailing Address - Zip Code:36509-0769
Mailing Address - Country:US
Mailing Address - Phone:251-824-2174
Mailing Address - Fax:251-824-2286
Practice Address - Street 1:12701 PADGETT SWITCH RD
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-4011
Practice Address - Country:US
Practice Address - Phone:251-824-2174
Practice Address - Fax:251-824-3444
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.12358208M00000X
AL12358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-47527Medicaid
AL107424Medicaid
AL510-47528OtherBCBS
AL1790734788OtherTRICARE SOUTH
AL107422Medicaid
AL631500002Medicaid
AL107424Medicaid
AL1790734788OtherTRICARE SOUTH
AL107422Medicaid
ALP00777444Medicare PIN