Healthcare Provider Details

I. General information

NPI: 1215559687
Provider Name (Legal Business Name): ROBERT NOLAN BRACKENRICH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 10/20/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SAINT JOSEPHS CANDLER DR STE 200
POOLER GA
31322-9585
US

IV. Provider business mailing address

101 SAINT JOSEPHS CANDLER DR STE 200
POOLER GA
31322-9585
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-1999
  • Fax:
Mailing address:
  • Phone: 912-748-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number97632
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: