MEDICARE: BRAVO HEALTH ADVANCED CARE CENTER, P.C.

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	MD038974E	PA

General Provider Information

NPI Number	:	1265674592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRAVO HEALTH ADVANCED CARE CENTER, P.C.

Provider Business Mailing Address
First Line	:	1500 SPRING GARDEN ST STE 800
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-4071
Country	:	US
Telephone Number	:	267-238-5825
Fax Number	:	855-803-5322

Provider Business Practice Location Address
First Line	:	1601 CHESTNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19192-4071
Country	:	US
Telephone Number	:	267-238-5825
Fax Number	:	855-803-5322

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIRK WALES
Credential	:	MD
Telephone Number	:	615-236-6100

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	12/03/2019

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