Basic Information
| Provider Information | |||||||||
| NPI: | 1760476519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BITTLE | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315583 | ||||||||
| FaxNumber: | 5733315079 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 S MOUNT AUBURN RD | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637034914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315544 | ||||||||
| FaxNumber: | 5733315545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 2006023028 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 2006023028 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 200387790 | 05 | IN | MEDICAID | 1760476519 | 05 | IL | MEDICAID | 7100095140 | 05 | KY | MEDICAID | 165391001 | 05 | AR | MEDICAID | 536594 | 01 | MO | ANTHEM BCBS | OTHER | 206881716 | 05 | MO | MEDICAID | P00382733 | 01 | MO | RR MCR | OTHER | 248625 | 01 | MO | HEALTHLINK | OTHER |