1982149811 NPI number — MRS. SAMANTHA CARA BRAVO P.A.

Table of content: MRS. SAMANTHA CARA BRAVO P.A. (NPI 1982149811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982149811 NPI number — MRS. SAMANTHA CARA BRAVO P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAVO
Provider First Name:
SAMANTHA
Provider Middle Name:
CARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLAUM
Provider Other First Name:
SAMANTHA
Provider Other Middle Name:
CARA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982149811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 STEWART AVENUE
Provider Second Line Business Mailing Address:
SUITE 100 NORTH
Provider Business Mailing Address City Name:
GARDEN CITY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-838-8739
Provider Business Mailing Address Fax Number:
516-992-4637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 STEWART AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100 NORTH
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-838-8739
Provider Business Practice Location Address Fax Number:
516-992-4637
Provider Enumeration Date:
01/02/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  020416 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A400185700 . This is a "MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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