Basic Information
| Provider Information | |||||||||
| NPI: | 1861477143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 NATURE PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GREENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156016960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248365540 | ||||||||
| FaxNumber: | 7248365548 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 NATURE PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GREENSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156016960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7248365540 | ||||||||
| FaxNumber: | 7248365548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | OS006954L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 001461835 | 05 | PA | MEDICAID | 10923530 | 01 | CAQH | OTHER |