Provider Demographics
NPI:1073868139
Name:BRADLEY AXLINE MD OBSTETRICS AND GYNECOLOGY , PA
Entity Type:Organization
Organization Name:BRADLEY AXLINE MD OBSTETRICS AND GYNECOLOGY , PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:NIZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:AHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-391-4184
Mailing Address - Street 1:1408 DEER PATH
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022
Mailing Address - Country:US
Mailing Address - Phone:301-591-4184
Mailing Address - Fax:972-559-3634
Practice Address - Street 1:1408 DEER PATH
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022
Practice Address - Country:US
Practice Address - Phone:301-591-4184
Practice Address - Fax:972-559-3634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8198207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty