Provider Demographics
NPI:1417129982
Name:MALLORY, BRAD MORRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:MORRIS
Last Name:MALLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:310 N L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1300
Mailing Address - Country:US
Mailing Address - Phone:270-651-1111
Mailing Address - Fax:270-659-5850
Practice Address - Street 1:310 N L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-651-1111
Practice Address - Fax:270-659-5850
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43602207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100134820Medicaid
KYP00975100OtherMEDICARE RAILROAD
KYP00975100OtherMEDICARE RAILROAD