Provider Demographics
NPI:1437171600
Name:BRADLEY, MARLY (MD)
Entity Type:Individual
Prefix:
First Name:MARLY
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARLY
Other - Middle Name:
Other - Last Name:PIERRE-JEROME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2449 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:317-870-6705
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:702 BARNHILL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5128
Practice Address - Country:US
Practice Address - Phone:317-274-3936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010529502080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200281390Medicaid