Basic Information
| Provider Information | |||||||||
| NPI: | 1598754640 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRACKIN | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2105 KLOCKNER RD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086903403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095880770 | ||||||||
| FaxNumber: | 6095880454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MA069724 | NJ | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 25MA06972400 | NJ | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.