Provider Demographics
NPI:1427602960
Name:BRAVO MEDICAL, LLC
Entity type:Organization
Organization Name:BRAVO MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORP DIR OF PATIENT ACCOUNTS
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-994-2968
Mailing Address - Street 1:2701 RENAISSANCE BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2781
Mailing Address - Country:US
Mailing Address - Phone:610-994-2968
Mailing Address - Fax:
Practice Address - Street 1:10 SOMERDALE SQUARE 1200 SOUTH WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1345
Practice Address - Country:US
Practice Address - Phone:856-679-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone