Provider Demographics
NPI:1285640318
Name:MULLEN, BRADLEY GERARD (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GERARD
Last Name:MULLEN
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-212-7000
Mailing Address - Fax:859-212-7010
Practice Address - Street 1:4900 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4824
Practice Address - Country:US
Practice Address - Phone:859-212-7000
Practice Address - Fax:859-212-7010
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27835207T00000X, 208VP0000X, 208VP0014X
OH35-061467207T00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0828108Medicaid
KY64867476Medicaid
KYK034130Medicare PIN
KY64867476Medicaid