Provider Demographics
NPI:1184633059
Name:MILLER, BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:MMC 404 UNIVERSITY OF MINNESOTA
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-624-5409
Mailing Address - Fax:612-626-5262
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:MMC 404 UNIVERSITY OF MINNESOTA
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-624-5409
Practice Address - Fax:612-626-5262
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41017208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
33-00127OtherMEDICA CHOICE/SELECT CARE
HP27040OtherHEALTHPARTNERS
126279OtherUCARE
MN930078007OtherMN RR
WI006136Medicaid
33-00031OtherMEDICA PRIMARY
MN548A4MIOtherBCBS-MN
PHCSOther929357
MT006136Medicaid
96198101860OtherPREFERRED ONE
PHCSOther929357