Provider Demographics
NPI:1437183597
Name:BRADLEY, ROBERT L (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:# L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-6052
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1050 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-7778
Practice Address - Fax:740-375-8118
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA08134367500000X
OHCOA.08134-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2541208Medicaid
OH8234811Medicare PIN
OHH060301Medicare PIN