Provider Demographics
NPI:1023202736
Name:BRANSON PULMONOLOGY LLC
Entity type:Organization
Organization Name:BRANSON PULMONOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-230-8070
Mailing Address - Street 1:545 BRANSON LANDING BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-4055
Mailing Address - Country:US
Mailing Address - Phone:417-230-8070
Mailing Address - Fax:417-336-1280
Practice Address - Street 1:545 BRANSON LANDING BLVD STE 301
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4055
Practice Address - Country:US
Practice Address - Phone:417-230-8070
Practice Address - Fax:417-336-1280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015440207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507601300Medicaid
MO000015456OtherMEDICARE PTAN