1033165394 NPI number — DR. JERRY W BRACKETT M.D.

Table of content: DR. JERRY W BRACKETT M.D. (NPI 1033165394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033165394 NPI number — DR. JERRY W BRACKETT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACKETT
Provider First Name:
JERRY
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033165394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
607 CHESTNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEREA
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40403-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-582-9331
Provider Business Mailing Address Fax Number:
606-789-5600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
607 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEREA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40403-1514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-582-9331
Provider Business Practice Location Address Fax Number:
606-789-5600
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  14390 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000059655 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64143902 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 611139169 . This is a "HUMANA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 340002395 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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