Provider Demographics
NPI:1952542615
Name:DOMENICK BRACCIA D.O.
Entity type:Organization
Organization Name:DOMENICK BRACCIA D.O.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-924-0600
Mailing Address - Street 1:2010 W CHESTER PIKE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2700
Mailing Address - Country:US
Mailing Address - Phone:610-924-0600
Mailing Address - Fax:610-924-0627
Practice Address - Street 1:2010 W CHESTER PIKE
Practice Address - Street 2:SUITE 310
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2700
Practice Address - Country:US
Practice Address - Phone:610-924-0600
Practice Address - Fax:610-924-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006737L261QH0100X, 261QI0500X, 261QM1300X, 261QP3300X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012371310008Medicaid
PA1794675OtherBLUE SHIELD
PA648523OtherBLUE SHIELD
PA648589Medicare PIN
PA648523OtherBLUE SHIELD