Provider Demographics
NPI:1275702284
Name:RICHARD C BRADLEY, DPM, PC
Entity Type:Organization
Organization Name:RICHARD C BRADLEY, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRADLETY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-629-7300
Mailing Address - Street 1:188 FRIES MILL RD
Mailing Address - Street 2:SUITE D-2
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2015
Mailing Address - Country:US
Mailing Address - Phone:856-629-7300
Mailing Address - Fax:856-629-8729
Practice Address - Street 1:188 FRIES MILL RD
Practice Address - Street 2:SUITE D-2
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-2015
Practice Address - Country:US
Practice Address - Phone:856-629-7300
Practice Address - Fax:856-629-8729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-23
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00213000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
114550000OtherKEYSTONE
AMERIHEALTHOther114550000
NJ5172101Medicaid
NJ5172101Medicaid
114550000OtherKEYSTONE
PA601173Medicare PIN