Basic Information
| Provider Information | |||||||||
| NPI: | 1396708442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHIPPS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4951 W. 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858322865 | ||||||||
| FaxNumber: | 7858413129 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858416540 | ||||||||
| FaxNumber: | 7858654214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 03/05/2010 | ||||||||
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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 | 207Q00000X | 420176 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100201720C | 05 | KS | MEDICAID |