Provider Demographics
NPI:1417957374
Name:PERSONIUS, BRADLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:PERSONIUS
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 1:520 MEDICAL CENTER DRIVE
Mailing Address - Street 2:STE 200
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4314
Mailing Address - Country:US
Mailing Address - Phone:541-282-6606
Mailing Address - Fax:541-282-6601
Practice Address - Street 1:520 SW RAMSEY AVE
Practice Address - Street 2:STE 101
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5573
Practice Address - Country:US
Practice Address - Phone:541-282-6606
Practice Address - Fax:541-282-6601
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21214207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151300Medicaid
OR102165Medicare ID - Type Unspecified
OR151300Medicaid