Healthcare Provider Details

I. General information

NPI: 1578539672
Provider Name (Legal Business Name): THOMAS MARK BRAXTON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 03/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER CIR
MAYFIELD KY
42066-1194
US

IV. Provider business mailing address

595 STATE ROUTE 408 E
HICKORY KY
42051-9537
US

V. Phone/Fax

Practice location:
  • Phone: 270-251-4085
  • Fax:
Mailing address:
  • Phone: 270-804-9727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43829
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43065
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number43065
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number43829
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number00024642
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: