Provider Demographics
NPI:1528358322
Name:BRAVO GERIATRICS
Entity Type:Organization
Organization Name:BRAVO GERIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-990-3222
Mailing Address - Street 1:PO BOX 12674
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-2674
Mailing Address - Country:US
Mailing Address - Phone:520-990-3222
Mailing Address - Fax:520-867-6409
Practice Address - Street 1:4716 E BURNS ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3015
Practice Address - Country:US
Practice Address - Phone:520-990-3222
Practice Address - Fax:520-867-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43580207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145166OtherMEDICARE