Basic Information
| Provider Information | |||||||||
| NPI: | 1891094272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHER | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILDER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRADSHER | ||||||||
| OtherFirstName: | ROB | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 251 S CLAYBROOK AVE | ||||||||
| Address2: | 2ND FLOOR, MED ED | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015168255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1265 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015168255 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 50878 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 50878 | TN | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 9663 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.