Healthcare Provider Details

I. General information

NPI: 1689907206
Provider Name (Legal Business Name): NICHOLAS BRANSCOMB D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NIC T BRANSCOMB D.O

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36475 FIVE MILE ROAD
LIVONIA MI
48154-1971
US

IV. Provider business mailing address

525 BRENT LN
PENSACOLA FL
32503-2003
US

V. Phone/Fax

Practice location:
  • Phone: 734-655-1290
  • Fax: 734-655-1270
Mailing address:
  • Phone: 941-227-0791
  • Fax: 888-775-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101018979
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberUO2210
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: