Basic Information
| Provider Information | |||||||||
| NPI: | 1447246186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAZZELL | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703473492 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705753247 | ||||||||
| FaxNumber: | 2704427335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 19912 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2084A0401X | 19912 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 207Q00000X | 19912 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00919781 | 01 | KY | RR MEDICARE | OTHER | 64199128 | 05 | KY | MEDICAID |