Provider Demographics
NPI:1275873275
Name:TIMOTHY M BRADLEY,MD SC
Entity Type:Organization
Organization Name:TIMOTHY M BRADLEY,MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-531-3199
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32549-0747
Mailing Address - Country:US
Mailing Address - Phone:618-531-3199
Mailing Address - Fax:
Practice Address - Street 1:1032 MAR WALT DR
Practice Address - Street 2:SUITE 240
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6661
Practice Address - Country:US
Practice Address - Phone:850-533-0865
Practice Address - Fax:850-314-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111099208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty