Basic Information
| Provider Information | |||||||||
| NPI: | 1568904480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADLEY BIBB, MD PLLC | ||||||||
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| OtherOrganizationName: | ACCESS MEDICAL CLINIC DARDANELLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 HIGHWAY 62 412 | ||||||||
| Address2: | |||||||||
| City: | ASH FLAT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725139594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 8709947488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1176 STATE HIGHWAY 22 W STE B | ||||||||
| Address2: | |||||||||
| City: | DARDANELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792293004 | ||||||||
| FaxNumber: | 8709947488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BIBB | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8709947301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 5G523 | 01 | AR | MEDICARE | OTHER |