Provider Demographics
NPI:1073055182
Name:TATE, BRAD EDWARD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:EDWARD
Last Name:TATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6713 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2656
Mailing Address - Country:US
Mailing Address - Phone:440-417-8685
Mailing Address - Fax:
Practice Address - Street 1:6713 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-2656
Practice Address - Country:US
Practice Address - Phone:440-417-8685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0173071Medicaid