Provider Demographics
NPI:1437339280
Name:MIGUEL A BRAVO MD SURGICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:MIGUEL A BRAVO MD SURGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-602-7707
Mailing Address - Street 1:420 S JAMES ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-3206
Mailing Address - Country:US
Mailing Address - Phone:330-602-7707
Mailing Address - Fax:330-602-6071
Practice Address - Street 1:420 S JAMES ST
Practice Address - Street 2:SUITE B
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-3206
Practice Address - Country:US
Practice Address - Phone:330-602-7707
Practice Address - Fax:330-602-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH52476174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0933315Medicaid
OH0933315Medicaid