Basic Information
| Provider Information | |||||||||
| NPI: | 1124000518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 GRAHAM RD W | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072572188 | ||||||||
| FaxNumber: | 6072667341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2005 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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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 | 208000000X | 216716 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 216716 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 10867 | 01 | NY | TOTALCARE/MANAGED MA | OTHER | 000136319 | 01 | BLUE SHIELD/HMO/EXCELLUS | OTHER | 02223650 | 05 | NY | MEDICAID | 00920290002 | 01 | HEALTH NOW | OTHER | V018315 | 01 | TRICARE | OTHER | 161010811 | 01 | RMSCO | OTHER | 161010811 | 01 | COMMERCIAL CARRIERS | OTHER |