Basic Information
| Provider Information | |||||||||
| NPI: | 1699097436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADLEY BIBB MD PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 HIGHWAY 62 412 | ||||||||
| Address2: | |||||||||
| City: | ASH FLAT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725139594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709947301 | ||||||||
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| Practice Location | |||||||||
| Address1: | 49 HIGHWAY 62 412 | ||||||||
| Address2: | |||||||||
| City: | ASH FLAT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725139594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709947301 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2010 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | BIBB | ||||||||
| AuthorizedOfficialFirstName: | BRADLEY | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8702572141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-4136 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204415002 | 05 | AR | MEDICAID |