Provider Demographics
NPI:1346367190
Name:BAGAN, BRADLEY T (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:T
Last Name:BAGAN
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 735
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-0735
Mailing Address - Country:US
Mailing Address - Phone:312-318-1309
Mailing Address - Fax:
Practice Address - Street 1:712 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3279
Practice Address - Country:US
Practice Address - Phone:847-362-1848
Practice Address - Fax:847-362-3351
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD71456207T00000X
IL036-114948207T00000X
IA38274207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA44067038Medicare PIN