Provider Demographics
NPI:1497193270
Name:FREDRICK J BRADSHAW MD & JOYCE J BRADSHAW MD INC
Entity Type:Organization
Organization Name:FREDRICK J BRADSHAW MD & JOYCE J BRADSHAW MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-636-0097
Mailing Address - Street 1:1401 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4030
Mailing Address - Country:US
Mailing Address - Phone:601-636-0097
Mailing Address - Fax:601-629-9969
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:601-636-0097
Practice Address - Fax:601-629-9969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09744207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C12816Medicare PIN