Provider Demographics
NPI:1568564672
Name:BRACKETT, RICHARD W (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:BRACKETT
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 1:6145 SHALLOWFORD RD
Mailing Address - Street 2:STE 102
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-893-6890
Mailing Address - Fax:423-648-1115
Practice Address - Street 1:6145 SHALLOWFORD RD
Practice Address - Street 2:STE 102
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-893-6890
Practice Address - Fax:423-648-1115
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16562207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3731246Medicaid
TN4110715OtherBLUE CROSS BLUE SHIELD
TN3731246Medicaid
E39255Medicare UPIN