Basic Information
| Provider Information | |||||||||
| NPI: | 1881641116 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRATHWAITE | ||||||||
| FirstName: | CORYSE | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816469 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434811000 | ||||||||
| FaxNumber: | 4434816933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 12/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D46239 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 5769117 | 01 | AETNA PPO | OTHER | 590811600 | 05 | MD | MEDICAID | 250AAA53270803 | 01 | CAREFIRST MD | OTHER | 55880010 | 01 | CAREFIRST DC | OTHER | 116546 | 01 | KAISER | OTHER | 6801338 | 01 | AETNA HMO | OTHER |