Basic Information
| Provider Information | |||||||||
| NPI: | 1235164138 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DRIVE | ||||||||
| Address2: | PHYSICIAN SUPPORT SERVICES | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792948 | ||||||||
| FaxNumber: | 9168587065 | ||||||||
| Practice Location | |||||||||
| Address1: | 2528 SISTER MARY COLUMBIA DRIVE | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960804327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305286100 | ||||||||
| FaxNumber: | 5305286146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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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 | 207X00000X | 4723 | AK | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | G79816 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | MD6033 | 05 | AK | MEDICAID |