Basic Information
| Provider Information | |||||||||
| NPI: | 1154577088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2839 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393022839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033480 | ||||||||
| FaxNumber: | 6017030124 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 22ND AVE | ||||||||
| Address2: | A | ||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393014016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017033830 | ||||||||
| FaxNumber: | 6015532069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 09/02/2014 | ||||||||
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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 | 2084N0400X | 22080 | MS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 03735301 | 05 | MS | MEDICAID |