Basic Information
Provider Information | |||||||||
NPI: | 1043248636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCELROY | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7648 | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420027648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705753113 | ||||||||
FaxNumber: | 2705753135 | ||||||||
Practice Location | |||||||||
Address1: | 2601 KENTUCKY AVE | ||||||||
Address2: | SUITE 301 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420033817 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2705753113 | ||||||||
FaxNumber: | 2705753135 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 12/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 27146 | KY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 64264286 | 05 | KY |   | MEDICAID | 2152 | 01 | KY | KENTUCKY BLS PROVIDER | OTHER | 610976324003 | 01 | KY | CHAMPUS ID# | OTHER | 060008622 | 01 | KY | RAILROAD MEDICARE PIN | OTHER |