Provider Demographics
NPI:1447201918
Name:ALLEN, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:ALLEN
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 1:130 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3116
Mailing Address - Country:US
Mailing Address - Phone:920-887-3102
Mailing Address - Fax:920-855-8790
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-887-3102
Practice Address - Fax:920-855-8790
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35870-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447201918Medicaid
WI080179058Medicare PIN
WI1447201918Medicaid
WI1013416OtherPHYSICIANS PLUS
WI080179058Medicare PIN
WIK400127415Medicare PIN
WI32073000Medicaid