Basic Information
Provider Information | |||||||||
NPI: | 1508039496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 602811 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282602811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 7 VANDERBILT PARK DR | ||||||||
Address2: |   | ||||||||
City: | ASHEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 288031700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8282557776 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2008 | ||||||||
LastUpdateDate: | 07/09/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | T-01840 | KS | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | TP294 | KY | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208VP0014X | 46441 | KY | N |   | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | 46441 | KY | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208100000X | 2014-01468 | NC | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 7100269040 | 05 | KY |   | MEDICAID |