Provider Demographics
NPI:1376634675
Name:BRAVO & SAN JUAN SC
Entity Type:Organization
Organization Name:BRAVO & SAN JUAN SC
Other - Org Name:ANTONIO BRAVO MD, SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-758-8610
Mailing Address - Street 1:1200 S YORK RD
Mailing Address - Street 2:SUITE 4120
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-5630
Mailing Address - Country:US
Mailing Address - Phone:630-833-1666
Mailing Address - Fax:630-833-1690
Practice Address - Street 1:1200 S YORK RD
Practice Address - Street 2:SUITE 4120
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5630
Practice Address - Country:US
Practice Address - Phone:630-833-1666
Practice Address - Fax:630-833-1690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty