Provider Demographics
NPI:1891729281
Name:BROUSSEAU, MICHAEL PHILIPPE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIPPE
Last Name:BROUSSEAU
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:120 S SPALDING DR
Mailing Address - Street 2:SUITE 403
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-1800
Mailing Address - Country:US
Mailing Address - Phone:424-239-2400
Mailing Address - Fax:424-239-2403
Practice Address - Street 1:120 S SPALDING DR
Practice Address - Street 2:SUITE 403
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1800
Practice Address - Country:US
Practice Address - Phone:424-239-2400
Practice Address - Fax:424-239-2403
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG081370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB234617OtherMEDICARE PROVIDER NUMBER
CAWG81370BMedicare PIN