Provider Demographics
NPI:1326288812
Name:REATHERFORD, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:REATHERFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 BELCLARE RD
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4925
Mailing Address - Country:US
Mailing Address - Phone:217-454-0780
Mailing Address - Fax:
Practice Address - Street 1:221 NORTHEAST AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-672-5654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2009-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041334740163W00000X
IL209007657367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse