=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164448858
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS ROSS BRASWELL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2006
-----------------------------------------------------
Last Update Date | 07/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15033 HIGHWAY 165
-----------------------------------------------------
City | SCOTT
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72142-9555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-552-7999
-----------------------------------------------------
Fax | 501-552-7998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 SAINT VINCENT CIR
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-552-7999
-----------------------------------------------------
Fax | 501-552-7998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C-5370
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------