Provider Demographics
NPI:1871024968
Name:BROUSSARD, IAN MATTHEW (DO)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 82ND PKWY
Mailing Address - Street 2:GRAND STRAND MEDICAL CENTER GME OFFICE
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:843-692-1752
Mailing Address - Fax:843-692-1904
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:GRAND STRAND MEDICAL CENTER GME OFFICE
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1752
Practice Address - Fax:843-692-1904
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC390200000X
SCLL41064207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program