Provider Demographics
NPI:1992715742
Name:BEESON, BROADUS MONROE (MD)
Entity type:Individual
Prefix:DR
First Name:BROADUS
Middle Name:MONROE
Last Name:BEESON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2093
Mailing Address - Fax:423-857-2012
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 3800
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-990-2466
Practice Address - Fax:423-990-2407
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000014671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513307Medicaid
VA1992715742Medicaid
VAMC12063Medicare UPIN
TN1513307Medicaid
VA1992715742Medicaid
TN103I086169Medicare UPIN