Basic Information
| Provider Information | |||||||||
| NPI: | 1033303862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Credential: | PT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 313 N WEBER RD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604901569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307710850 | ||||||||
| FaxNumber: | 6307710852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 01/20/2016 | ||||||||
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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 | 225100000X | 070009229 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 05007954A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 01622333 | 01 | BLUE CROSS BLUE SHIELD ID | OTHER | 7454077 | 01 | AETNA | OTHER |