Provider Demographics
NPI:1437187820
Name:DR BRAD WILLIAMS PC
Entity Type:Organization
Organization Name:DR BRAD WILLIAMS PC
Other - Org Name:AGILITY ORTHOPEDICS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-634-1112
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6744
Mailing Address - Country:US
Mailing Address - Phone:928-634-0323
Mailing Address - Fax:928-634-1144
Practice Address - Street 1:299 S WILLARD STREET
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6744
Practice Address - Country:US
Practice Address - Phone:928-634-0323
Practice Address - Fax:928-634-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
AZ35254207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ099069Medicaid
AZ099069Medicaid