Basic Information
Provider Information | |||||||||
NPI: | 1245340280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRATZKE | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | CHARLES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 18139 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276198139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4420 LAKE BOONE TRL | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276077505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197843034 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 03/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 9601244 | NC | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | 9601244 | NC | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 050047833 | 01 | NC | RAILROAD-MEDICARE | OTHER | 132EC | 01 | NC | BCBS, NC | OTHER | 89132EC | 05 | NC |   | MEDICAID | 21765 | 01 | NC | PARTNERS | OTHER | 67718 | 01 | NC | MEDCOST | OTHER | 5263154 | 01 | NC | CIGNA | OTHER |