Provider Demographics
NPI:1144223082
Name:BRADLEY, TINA NAYLOR (MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:NAYLOR
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:301 GORDON GUTMANN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3765
Practice Address - Country:US
Practice Address - Phone:812-282-4844
Practice Address - Fax:812-282-6248
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058849A207R00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01058849AOtherSTATE LICENSE
KY64087315Medicaid
KY38451OtherSTATE LICENSE
IN200495720Medicaid