MEDICARE: RICHARD S BRAGG MD PA

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	261QP2300X	Primary Care Clinic/Center	ME0065139	FL

General Provider Information

NPI Number	:	1194000554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD S BRAGG MD PA

Provider Business Mailing Address
First Line	:	580 RINEHART RD
Second Line	:	SUITE 110
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1551
Country	:	US
Telephone Number	:	407-805-8989
Fax Number	:

Provider Business Practice Location Address
First Line	:	580 RINEHART RD
Second Line	:	SUITE 110
City	:	LAKE MARY
State	:	FL
Zip	:	32746-1551
Country	:	US
Telephone Number	:	407-805-8989
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD BRAGG
Credential	:	MD
Telephone Number	:	407-805-8989

Provider Enumeration Date	:	10/18/2011
Last Update Date	:	10/18/2011

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