Basic Information
| Provider Information | |||||||||
| NPI: | 1801878046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | BELMONT | ||||||||
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| Credential: | MD | ||||||||
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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: | 11/15/2005 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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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 | 207V00000X | 35042423 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0492864 | 05 | OH | MEDICAID |