Basic Information
| Provider Information | |||||||||
| NPI: | 1386612398 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRACKEN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | BRUCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 3 SOUTH, CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5134757239 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 PIEDMONT AVE | ||||||||
| Address2: | STE. 7000 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452194231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5134757239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/17/2015 | ||||||||
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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 | 208800000X | 35-046750 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0505395 | 05 | OH | MEDICAID | 64780364 | 05 | KY | MEDICAID | 100328150 | 05 | IN | MEDICAID |