MEDICARE: BRAVO & SAN JUAN SC

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	207V00000X	Obstetrics & Gynecology Physician		IL

General Provider Information

NPI Number	:	1376634675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVO & SAN JUAN SC

Provider Business Mailing Address
First Line	:	1200 S YORK RD
Second Line	:	SUITE 4120
City	:	ELMHURST
State	:	IL
Zip	:	60126-5630
Country	:	US
Telephone Number	:	630-833-1666
Fax Number	:	630-833-1690

Provider Business Practice Location Address
First Line	:	1200 S YORK RD
Second Line	:	SUITE 4120
City	:	ELMHURST
State	:	IL
Zip	:	60126-5630
Country	:	US
Telephone Number	:	630-833-1666
Fax Number	:	630-833-1690

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. MIRIAM B MILLER
Credential	:
Telephone Number	:	630-758-8610

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	05/15/2009

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Directions to “BRAVO & SAN JUAN SC ” Practice Location

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