Basic Information
| Provider Information | |||||||||
| NPI: | 1518057140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKLOW | ||||||||
| FirstName: | BRADFORD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE STE 115 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513121505 | ||||||||
| FaxNumber: | 6122482944 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 CHICAGO AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512257855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 02/27/2018 | ||||||||
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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 | 208600000X | 5317240-1205 | UT | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 57096 | MN | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00039720 | 01 | UT | RAILROAD MEDICARE | OTHER |