Provider Demographics
NPI:1326083023
Name:BERRY, BRADLEY D (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:D
Last Name:BERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 W BROADWAY ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4003
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-5606
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:SUITE 320
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4003
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-5606
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT10148207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0049556Medicaid
MT0049556Medicaid