Provider Demographics
NPI:1972603744
Name:BRACKENRICH, MICHAEL DALE (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:BRACKENRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 WOODLAND ST
Mailing Address - Street 2:PO BOX B
Mailing Address - City:RICH CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:24147
Mailing Address - Country:US
Mailing Address - Phone:540-726-2375
Mailing Address - Fax:540-726-3573
Practice Address - Street 1:363 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:RICH CREEK
Practice Address - State:VA
Practice Address - Zip Code:24147-0336
Practice Address - Country:US
Practice Address - Phone:540-726-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102036943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005696208Medicaid
VAC10672Medicare UPIN
VA080002029Medicare ID - Type Unspecified