Healthcare Provider Details

I. General information

NPI: 1770557753
Provider Name (Legal Business Name): ROBERTA SAMELSON BRACKEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 COURTHOUSE DR NE
BOLIVIA NC
28422
US

IV. Provider business mailing address

25 COURTHOUSE DRIVE NE P O BOX 9
BOLIVIA NC
28422
US

V. Phone/Fax

Practice location:
  • Phone: 910-253-2250
  • Fax: 910-253-2370
Mailing address:
  • Phone: 910-253-2250
  • Fax: 910-253-2370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number35280
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: