Basic Information
| Provider Information | |||||||||
| NPI: | 1215971288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUMRALL | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 405827 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303845827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709345821 | ||||||||
| FaxNumber: | 8709345384 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 BAPTIST BLVD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622442288 | ||||||||
| FaxNumber: | 6622442289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/15/2010 | ||||||||
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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 | 363AS0400X | PA00066 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 04729081 | 05 | MS | MEDICAID |