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General NPI Number Information
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NPI Number | 1801100177
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Entity Type | Organization
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Legal Business Name | BRIDGE MEDICINE LLC
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Dates
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Enumeration Date | 07/28/2010
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Last Update Date | 07/28/2010
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Provider Practice Location Address
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Address Line | 1120A MAKAWAO AVE
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City | MAKAWAO
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State | HI
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Zip | 96768-9448
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Country | US
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Telephone | 808-573-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 1120A MAKAWAO AVE
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City | MAKAWAO
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State | HI
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Zip | 96768-9448
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Country | US
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Telephone | 808-573-7555
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. MIA CARSON
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Credential | MD
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Telephone | 808-573-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 13323
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License Number State | HI
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