Provider Demographics
NPI:1356326136
Name:BLACK, BRADFORD THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:THOMAS
Last Name:BLACK
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 1:2777 CARRINGTON ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8163
Mailing Address - Country:US
Mailing Address - Phone:330-244-0515
Mailing Address - Fax:
Practice Address - Street 1:885 S SAWBURG RD
Practice Address - Street 2:SUITE 105
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-5905
Practice Address - Country:US
Practice Address - Phone:330-823-1112
Practice Address - Fax:330-823-1139
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58282208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0738536Medicaid
OH340012867OtherMEDICARE RAILROAD
BL0638906Medicare ID - Type UnspecifiedSALEM
OH4238110001Medicare NSC
OH340012867OtherMEDICARE RAILROAD
BL0638905Medicare ID - Type UnspecifiedALLIANCE