Provider Demographics
NPI:1134243017
Name:JENNIFER BROYLES MD LLC
Entity type:Organization
Organization Name:JENNIFER BROYLES MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BROYLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-837-6000
Mailing Address - Street 1:PO BOX 8487
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37414-0487
Mailing Address - Country:US
Mailing Address - Phone:423-899-2204
Mailing Address - Fax:423-698-4045
Practice Address - Street 1:1511 MAIN ST
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:TN
Practice Address - Zip Code:37347-5551
Practice Address - Country:US
Practice Address - Phone:423-837-6000
Practice Address - Fax:423-837-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3370123OtherMEDICARE PTAN