Basic Information
| Provider Information | |||||||||
| NPI: | 1659543676 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALAN B BRADLEY MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 E ELM ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192242632 | ||||||||
| FaxNumber: | 4192222731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 E ELM ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458042850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192242632 | ||||||||
| FaxNumber: | 4192222731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 03/31/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRADLEY | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4192242632 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35042423B | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0492864 | 05 | OH | MEDICAID |