Provider Demographics
NPI:1649286204
Name:BRAICH, THEODORE ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ANTHONY
Last Name:BRAICH
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-5800
Mailing Address - Fax:541-706-6341
Practice Address - Street 1:2500 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6015
Practice Address - Country:US
Practice Address - Phone:541-706-5800
Practice Address - Fax:541-706-6341
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24320174400000X, 207RX0202X, 207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No174400000XOther Service ProvidersSpecialist
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00411275OtherMEDICARE RAILROAD
ORP00411275OtherMEDICARE RAILROAD
OR226900Medicaid
ORP00411275OtherMEDICARE RAILROAD
ORD43727Medicare UPIN