Provider Demographics
NPI:1770525438
Name:BRACKEN, ANTHONY W (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:W
Last Name:BRACKEN
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10650 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8538
Practice Address - Country:US
Practice Address - Phone:704-667-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39398207RI0011X, 207RC0000X, 207R00000X, 207RI0001X, 207RC0000X
SC15102207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8917418Medicaid
P00343758OtherRAILROAD MEDICARE
NC1770525438Medicaid
NC17418OtherBCBS
SCTL4546Medicaid
SCTL4546Medicaid
NC1770525438Medicaid
NCNC3590BMedicare PIN
NC2165891EMedicare PIN
NC17418OtherBCBS
B42059Medicare UPIN
SCSC27748186Medicare PIN