Basic Information
| Provider Information | |||||||||
| NPI: | 1669056669 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADFORD RADIOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 199 PARK CLUB LN STE 300 | ||||||||
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| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142215269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168364646 | ||||||||
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| Practice Location | |||||||||
| Address1: | 116 INTERSTATE PKWY | ||||||||
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| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143684143 | ||||||||
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| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | PEARSEN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 7168364646 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.