Basic Information
| Provider Information | |||||||||
| NPI: | 1154390227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACKEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | HOWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 09/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25608 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01-19433 | 01 | MN | MEDICA ISLE CLINIC | OTHER | 06F85BR | 01 | MN | BLUE CROSS HOSPITAL | OTHER | HP20616 | 01 | MN | HEALTH PARTNERS | OTHER | 108798 | 01 | MN | UCARE | OTHER | 18358 | 05 | ND | MEDICAID | 7703540 | 05 | SD | MEDICAID | 01-29391 | 01 | MN | MEDICA HILLMAN CLINIC | OTHER | 33524BR | 01 | MN | BLUE CROSS | OTHER | 01-19434 | 01 | MN | MEDICA ONAMIA CLINIC | OTHER | 225208200 | 05 | MN | MEDICAID | NA9090733003 | 01 | MN | PREFERRED ONE | OTHER |