NPIMap

Organization Active NPI

Bravo Iom LLC

  • Electrodiagnostic Medicine Physician
  • Ft Worth, TX
National Provider Identifier
1003372285
Registry record updated Feb 13, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Electrodiagnostic Medicine PhysicianTaxonomy code 204R00000X
Legal business name
BRAVO IOM LLC
Practice address
111 Boland St Ste 211
Ft Worth, TX 76107-1265
Phone
(817) 529-8488
Fax
(903) 328-6568
NPI assigned
Feb 13, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 13, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gina Sulllivan
Title
Billing Manager
Phone
(817) 528-8488

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Electrodiagnostic Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 204R00000X Primary

Addresses

Primary practice location

111 Boland St Ste 211
Ft Worth, TX 76107-1265

Mailing address

111 Boland St Ste 211
Ft Worth, TX 76107-1265
Phone (817) 529-8488

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1550016000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1550016000000",
    "number": "1003372285",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 BOLAND ST STE 211",
            "city": "FT WORTH",
            "state": "TX",
            "postal_code": "761071265",
            "telephone_number": "817-529-8488"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 BOLAND ST STE 211",
            "city": "FT WORTH",
            "state": "TX",
            "postal_code": "761071265",
            "telephone_number": "817-529-8488",
            "fax_number": "903-328-6568"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRAVO IOM LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-13",
        "last_updated": "2019-02-13",
        "status": "A",
        "authorized_official_last_name": "SULLLIVAN",
        "authorized_official_first_name": "GINA",
        "authorized_official_title_or_position": "BILLING MANAGER",
        "authorized_official_telephone_number": "817-528-8488"
    },
    "taxonomies": [
        {
            "code": "204R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Electrodiagnostic Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Ft Worth, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.