Basic Information
| Provider Information | |||||||||
| NPI: | 1730142902 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMICHAEL | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 NE SAINT LUKES BLVD | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640866000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164127004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 12/16/2014 | ||||||||
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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 | 207ZP0105X | 48622 | WI | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0102X | 2007011168 | MO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 32447 | KS | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 200537970B | 05 | KS | MEDICAID |