Provider Demographics
NPI:1275522567
Name:BRANTNER, JIM N (MD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:N
Last Name:BRANTNER
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 1:1303 SUNSET DR STE 5
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7905
Mailing Address - Country:US
Mailing Address - Phone:423-328-9000
Mailing Address - Fax:423-328-9007
Practice Address - Street 1:1303 SUNSET DR
Practice Address - Street 2:SUITE 5
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7905
Practice Address - Country:US
Practice Address - Phone:423-328-9000
Practice Address - Fax:423-328-9007
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD25117208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN178630OtherBLUECROSS BLUESHIELD
TN3081165Medicaid
TN178630OtherBLUECROSS BLUESHIELD
TN3081165Medicaid