Basic Information
| Provider Information | |||||||||
| NPI: | 1659364834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERBURNE | ||||||||
| FirstName: | BRADFORD | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 EAST RIVER DRIVE | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602820833 | ||||||||
| FaxNumber: | 8602820170 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 SEYMOUR STREET | ||||||||
| Address2: | PATHOLOGY DEPARTMENT | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605455000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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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 | 207ZH0000X | 037649 | CT | Y | Allopathic & Osteopathic Physicians | Pathology | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 001376492 | 05 | CT | MEDICAID |