Basic Information
| Provider Information | |||||||||
| NPI: | 1790096170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAVATA | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173286501 | ||||||||
| FaxNumber: | 4173286338 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 S ASH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656228674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173456100 | ||||||||
| FaxNumber: | 4173456866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2010 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2013030074 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | P01259379 | 01 | MO | PALMETTO GBA RAILROAD | OTHER |