Provider Demographics
NPI:1144200189
Name:DAVIS, BRADLEY DUANE (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DUANE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:EMERGENCY CENTER
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6222
Practice Address - Fax:864-560-4413
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC845207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7361552OtherAETNA
NC89067H3Medicaid
SC008459Medicaid
SC20030852OtherSELECT HEALTH OF SC
SC189202OtherMEDCOST
SC189202OtherMEDCOST
SCAA06269068Medicare PIN
SC20030852OtherSELECT HEALTH OF SC
SCAA06268510Medicare PIN
SCI166328510Medicare PIN
SCP00315088Medicare PIN