Basic Information
| Provider Information | |||||||||
| NPI: | 1396748877 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 0765 | ||||||||
| Address2: | PO BOX 11407 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352460765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563833325 | ||||||||
| FaxNumber: | 4802128451 | ||||||||
| Practice Location | |||||||||
| Address1: | 2114 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | TULLAHOMA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373882208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314549423 | ||||||||
| FaxNumber: | 9314549690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | MD0000025802 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 3867811 | 05 | TN | MEDICAID | 4019082 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |