Provider Demographics
NPI:1932535069
Name:BROADHEAD, RUSSELL L (HIS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3275 W INA RD STE 117
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2330
Mailing Address - Country:US
Mailing Address - Phone:520-230-3999
Mailing Address - Fax:520-230-3999
Practice Address - Street 1:3275 W INA RD STE 117
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-2330
Practice Address - Country:US
Practice Address - Phone:520-230-3999
Practice Address - Fax:888-240-3305
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADR9827237700000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist