Basic Information
| Provider Information | |||||||||
| NPI: | 1245432079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 234 E. GRAY STREET | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025851735 | ||||||||
| FaxNumber: | 5025265489 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 E. GRAY STREET | ||||||||
| Address2: | SUITE 850 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025851735 | ||||||||
| FaxNumber: | 5025265489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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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 | 2085R0202X | 01076129A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 40843 | KY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201334210 | 05 | IN | MEDICAID | 7100017740 | 05 | KY | MEDICAID |