Provider Demographics
NPI:1255475836
Name:BRASWELL, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BRASWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 BOBOLINK PL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-8107
Mailing Address - Country:US
Mailing Address - Phone:662-843-8880
Mailing Address - Fax:662-843-2280
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-843-8880
Practice Address - Fax:662-843-2280
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5294920001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER