Provider Demographics
NPI:1962404897
Name:BRAVETTE, BARRY ALAN (MD)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:ALAN
Last Name:BRAVETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:215-463-5333
Mailing Address - Fax:215-463-8085
Practice Address - Street 1:1703 S BROAD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19148-1536
Practice Address - Country:US
Practice Address - Phone:215-463-5333
Practice Address - Fax:215-463-8085
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037092E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012390380007Medicaid
PA661222GT6Medicare PIN
E77274Medicare UPIN