Provider Demographics
NPI:1740461201
Name:T. KEVIN BRASWELL, MD P.A.
Entity type:Organization
Organization Name:T. KEVIN BRASWELL, MD P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUSTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-226-2030
Mailing Address - Street 1:990 AVENT DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5002
Mailing Address - Country:US
Mailing Address - Phone:662-226-2030
Mailing Address - Fax:662-227-1236
Practice Address - Street 1:990 AVENT DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5002
Practice Address - Country:US
Practice Address - Phone:662-226-2030
Practice Address - Fax:662-227-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112536Medicaid
MS00112536Medicaid
MSCO2847Medicare PIN