Basic Information
| Provider Information | |||||||||
| NPI: | 1275529968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADENHAM | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2369 STAPLES MILL RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232302918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042854465 | ||||||||
| FaxNumber: | 8042858332 | ||||||||
| Practice Location | |||||||||
| Address1: | 7611 FOREST AVE | ||||||||
| Address2: | STE 410 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232294946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042852965 | ||||||||
| FaxNumber: | 8042820616 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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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 | 207RG0100X | 0101029475 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 006011420 | 05 | VA | MEDICAID |