MEDICARE: KEITH MICHAEL BRAVO MD

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	207R00000X	Internal Medicine Physician	19983	WV
2	208000000X	Pediatrics Physician	19983	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841286036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH MICHAEL BRAVO MD

Provider Business Mailing Address
First Line	:	PO BOX 2581
Second Line	:
City	:	WEIRTON
State	:	WV
Zip	:	26062-1781
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	651 COLLIERS WAY
Second Line	:	SUITE 502
City	:	WEIRTON
State	:	WV
Zip	:	26062-5053
Country	:	US
Telephone Number	:	304-723-4328
Fax Number	:	304-723-5814

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	07/29/2008

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