Basic Information
Provider Information | |||||||||
NPI: | 1295774040 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARMAN | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO FACOS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 449 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 457500449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403744500 | ||||||||
FaxNumber: | 7403745887 | ||||||||
Practice Location | |||||||||
Address1: | 400 MATTHEW ST | ||||||||
Address2: | SUITE 401 | ||||||||
City: | MARIETTA | ||||||||
State: | OH | ||||||||
PostalCode: | 457501644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7403742252 | ||||||||
FaxNumber: | 7403744974 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 08/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 34004869 | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 000000696936 | 01 | OH | ANTHEM | OTHER | 0817754 | 05 | OH |   | MEDICAID | 000000490579 | 01 | OH | ANTHEM | OTHER | 2034873 | 05 | OH |   | MEDICAID | P00789302 | 01 | OH | RRMCR | OTHER | 0125817000 | 05 | WV |   | MEDICAID |