1174628903 NPI number — DR. MICHAEL W BRUEGGEMAN M.D.

Table of content: DR. MICHAEL W BRUEGGEMAN M.D. (NPI 1174628903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174628903 NPI number — DR. MICHAEL W BRUEGGEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUEGGEMAN
Provider First Name:
MICHAEL
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:
1174628903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 WEST FOREST, STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-541-9490
Provider Business Mailing Address Fax Number:
731-541-9485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 WEST FOREST, STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-541-9490
Provider Business Practice Location Address Fax Number:
731-541-9485
Provider Enumeration Date:
09/14/2006

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: 2084N0400X , with the licence number:  13742 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0702090003 . This is a "PALMETTO GBA DME" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 38955 . This is a "MEMPHIS MANAGED CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4182440 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3008329 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130006552 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0050209 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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