1619031614 NPI number — THOMAS ANDREW BRACKBILL M.D.

Table of content: THOMAS ANDREW BRACKBILL M.D. (NPI 1619031614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619031614 NPI number — THOMAS ANDREW BRACKBILL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACKBILL
Provider First Name:
THOMAS
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
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:
1619031614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27401-1004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-832-7000
Provider Business Mailing Address Fax Number:
336-851-8427

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 N CHURCH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27401-1439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-272-6133
Provider Business Practice Location Address Fax Number:
336-271-9043
Provider Enumeration Date:
12/21/2006

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: 207RC0000X , with the licence number:  19909 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 561240263 . This is a "COMMERCIAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8915976 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 435 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 060041999 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 435 . This is a "PARTNERS MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 15976 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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