Provider Demographics
NPI:1710065271
Name:BRACKEBUSCH, JOYCE M (MD)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:M
Last Name:BRACKEBUSCH
Suffix:
Gender:F
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-791-2000
Mailing Address - Fax:
Practice Address - Street 1:146 E HOSPITAL DR STE 200
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4800
Practice Address - Country:US
Practice Address - Phone:803-936-7530
Practice Address - Fax:803-936-7532
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20476207Y00000X
SC89330207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150605Medicaid
G10476Medicare UPIN
ORR133545Medicare PIN