Provider Demographics
NPI:1154390227
Name:BRACKEN, THOMAS HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:HOWARD
Last Name:BRACKEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN25608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-19433OtherMEDICA ISLE CLINIC
MN06F85BROtherBLUE CROSS HOSPITAL
MNHP20616OtherHEALTH PARTNERS
MN108798OtherUCARE
ND18358Medicaid
SD7703540Medicaid
MN01-29391OtherMEDICA HILLMAN CLINIC
MN33524BROtherBLUE CROSS
MN01-19434OtherMEDICA ONAMIA CLINIC
MN225208200Medicaid
MNNA9090733003OtherPREFERRED ONE
MN33524BROtherBLUE CROSS
D48432Medicare UPIN
MN080014416Medicare ID - Type Unspecified
MN01-29391OtherMEDICA HILLMAN CLINIC
MNHP20616OtherHEALTH PARTNERS
MN089000777Medicare ID - Type Unspecified
MN080018109Medicare Oscar/Certification
MN225208200Medicaid