Provider Demographics
NPI:1467733352
Name:TUCKER, BRADLEY GORDON (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GORDON
Last Name:TUCKER
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 1:3737 MARKET ST FL 6
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5545
Mailing Address - Country:US
Mailing Address - Phone:215-294-9150
Mailing Address - Fax:
Practice Address - Street 1:3737 MARKET ST FL 6
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5545
Practice Address - Country:US
Practice Address - Phone:215-294-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD454327208100000X, 2081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation