Healthcare Provider Details

I. General information

NPI: 1811985500
Provider Name (Legal Business Name): GEORGE G BRACKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W STATE ST
DOYLESTOWN PA
18901-2554
US

IV. Provider business mailing address

227 LAUREL RD SUITE300
VOORHEES NJ
08043-8303
US

V. Phone/Fax

Practice location:
  • Phone: 215-345-2290
  • Fax: 215-345-2596
Mailing address:
  • Phone: 856-770-3044
  • Fax: 856-770-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD013255E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: