Healthcare Provider Details

I. General information

NPI: 1427602960
Provider Name (Legal Business Name): BRAVO MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SOMERDALE SQUARE 1200 SOUTH WHITE HORSE PIKE
SOMERDALE NJ
08083-1345
US

IV. Provider business mailing address

2701 RENAISSANCE BLVD FL 4
KING OF PRUSSIA PA
19406-2781
US

V. Phone/Fax

Practice location:
  • Phone: 856-679-2500
  • Fax:
Mailing address:
  • Phone: 610-994-2968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: MARK GALLIHUE
Title or Position: CORP DIR OF PATIENT ACCOUNTS
Credential:
Phone: 610-994-2968