Basic Information
| Provider Information | |||||||||
| NPI: | 1124016464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRETZ | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 E BANNOCK ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837126241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083812222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2537 W STATE ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837022200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083360895 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 01/10/2018 | ||||||||
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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 | 208VP0000X | M8818 | ID | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 207L00000X | M8818 | ID | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 227200 | 05 | OR | MEDICAID | 806623200 | 05 | ID | MEDICAID | P00036984 | 01 | ID | RAILROAD MEDICARE | OTHER | P00754805 | 01 | ID | RAILROAD MEDICARE | OTHER |