Basic Information
Provider Information | |||||||||
NPI: | 1942706668 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILAM | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | KEITH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3610 MINTWOOD ST | ||||||||
Address2: |   | ||||||||
City: | PITTSBURGH | ||||||||
State: | PA | ||||||||
PostalCode: | 152011331 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2038154505 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1070 OLD NATIONAL PIKE | ||||||||
Address2: |   | ||||||||
City: | FREDERICKTOWN | ||||||||
State: | PA | ||||||||
PostalCode: | 153332114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7246326801 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2018 | ||||||||
LastUpdateDate: | 07/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30288 | WV | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD472401 | PA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.