Basic Information
| Provider Information | |||||||||
| NPI: | 1023214509 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYER | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5325 FARAON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162716406 | ||||||||
| FaxNumber: | 8162717986 | ||||||||
| Practice Location | |||||||||
| Address1: | 5325 FARAON ST | ||||||||
| Address2: | MS 1020 DIVISION OF GENERAL AND GERIATRIC MEDICINE UNIV | ||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645063488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162716406 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 10/19/2017 | ||||||||
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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 | 207R00000X | 2015000100 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 05-35676 | KS | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 2015000100 | MO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1023214509 | 05 | MO | MEDICAID | 200865660C | 05 | KS | MEDICAID | P01434619 | 01 | MO | RR MEDICARE | OTHER |