Provider Demographics
NPI:1497821847
Name:CHARLES R BRADFORD MD PC
Entity Type:Organization
Organization Name:CHARLES R BRADFORD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-259-6054
Mailing Address - Street 1:508 HARLEY ST STE D
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-4263
Mailing Address - Country:US
Mailing Address - Phone:256-259-6054
Mailing Address - Fax:256-259-5206
Practice Address - Street 1:508 HARLEY ST STE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4263
Practice Address - Country:US
Practice Address - Phone:256-259-6054
Practice Address - Fax:256-259-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51003793OtherBLUE CROSS OF AL
AL51003793OtherBLUE CROSS OF AL