Provider Demographics
NPI:1215208608
Name:JEREMY BRADLEY MD PSC
Entity Type:Organization
Organization Name:JEREMY BRADLEY MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-684-7362
Mailing Address - Street 1:3122 COMMONWEALTH CT
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-2258
Mailing Address - Country:US
Mailing Address - Phone:270-684-7362
Mailing Address - Fax:270-684-7753
Practice Address - Street 1:3122 COMMONWEALTH CT
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2258
Practice Address - Country:US
Practice Address - Phone:270-684-7362
Practice Address - Fax:270-684-7753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31984207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64319841Medicaid
KY64319841Medicaid