Provider Demographics
NPI:1679798490
Name:MICHAEL P. BROUSSEAU, MD, INC.
Entity type:Organization
Organization Name:MICHAEL P. BROUSSEAU, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PHILIPPE
Authorized Official - Last Name:BROUSSEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-657-9200
Mailing Address - Street 1:150 N ROBERTSON BLVD
Mailing Address - Street 2:STE 115
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2142
Mailing Address - Country:US
Mailing Address - Phone:310-657-9200
Mailing Address - Fax:
Practice Address - Street 1:150 N ROBERTSON BLVD
Practice Address - Street 2:STE 115
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2142
Practice Address - Country:US
Practice Address - Phone:310-657-9200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG081370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W16915Medicare ID - Type Unspecified