Provider Demographics
NPI:1366477572
Name:BRADLEY, MICHELLE LEA (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:LEA
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:8301 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0083
Mailing Address - Country:US
Mailing Address - Phone:586-498-2400
Mailing Address - Fax:586-498-2800
Practice Address - Street 1:25311 LITTLE MACK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-3301
Practice Address - Country:US
Practice Address - Phone:586-498-2400
Practice Address - Fax:586-498-2800
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012404208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366477572Medicaid
MI5501254OtherBCBS PIN
G83780Medicare UPIN
MI495487811Medicaid