Healthcare Provider Details

I. General information

NPI: 1902158678
Provider Name (Legal Business Name): BRAVO HEALTH ADVANCED CARE CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 MARTIN LUTHER KING JR BLVD
BALTIMORE MD
21201-1221
US

IV. Provider business mailing address

312 MARTIN LUTHER KING JR BLVD STE 200
BALTIMORE MD
21201-1221
US

V. Phone/Fax

Practice location:
  • Phone: 443-278-7001
  • Fax:
Mailing address:
  • Phone: 443-278-7001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DIRK WALES
Title or Position: PRESIDENT
Credential: MD
Phone: 615-236-6162