Provider Demographics
NPI:1174737985
Name:BRACHMAN, GWEN ORR (MD)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ORR
Last Name:BRACHMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 BERGEN ST
Practice Address - Street 2:ADMC 12 1205
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3000
Practice Address - Country:US
Practice Address - Phone:973-972-0037
Practice Address - Fax:973-972-9355
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04674100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6639003Medicaid
NJF51854Medicare UPIN
NJ734512Medicare PIN