Provider Demographics
NPI:1073694535
Name:BRADLEY, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CRAWFORD PL STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3954
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:239 HURFFVILLE CROSSKEYS RD STE 160
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-341-8200
Practice Address - Fax:856-341-8215
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06165200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7134401Medicaid
NJ472831R63Medicare PIN
G44230Medicare UPIN
NJ472831YBAWMedicare PIN