MEDICARE: TARA BRAYBOY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	BP10060983	TX
2	207R00000X	Internal Medicine Physician	86673	GA

General Provider Information

NPI Number	:	1083148860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA BRAYBOY MD

Provider Business Mailing Address
First Line	:	PO BOX 742616
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-2616
Country	:	US
Telephone Number	:	770-219-8420
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 ANSLEY DR STE 400
Second Line	:
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-1642
Country	:	US
Telephone Number	:	706-864-1580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2017
Last Update Date	:	02/15/2021

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