Basic Information
| Provider Information | |||||||||
| NPI: | 1649230012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PADDOCK | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | HOLMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 242 E STATE ST EXT | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120786039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187258656 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 182 STEELE AVE LOWR LEVEL | ||||||||
| Address2: | |||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120784617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187258656 | ||||||||
| FaxNumber: | 5187737824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 150053 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | J400554086 | 01 | NY | MEDICARE PIN-NLH | OTHER | 00709682 | 05 | NY | MEDICAID |