Healthcare Provider Details

I. General information

NPI: 1619905924
Provider Name (Legal Business Name): JEFFREY REX BRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 HIGHWAY 36 W STE 100
ROSEVILLE MN
55113-3905
US

IV. Provider business mailing address

2355 HIGHWAY 36 W STE 100
ROSEVILLE MN
55113-3905
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-2000
  • Fax:
Mailing address:
  • Phone: 651-292-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number44515
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number44515
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: