Provider Demographics
NPI:1497860464
Name:NICHOLAS BRADLEE DPM PC
Entity Type:Organization
Organization Name:NICHOLAS BRADLEE DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-244-9565
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1029
Mailing Address - Country:US
Mailing Address - Phone:248-244-9565
Mailing Address - Fax:248-244-8183
Practice Address - Street 1:1909 LIVERNOIS
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-244-9565
Practice Address - Fax:248-244-8183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINB000558213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5635277OtherBLUE CROSS BLUE SHIELD
5635277OtherBLUE CROSS
8505050OtherBLUE SHIELD OF MICH
8505050OtherBLUE CROSS BLUE SHIELD
8505050OtherBLUE CROSS BLUE SHIELD
8505050OtherBLUE SHIELD OF MICH
5635277OtherBLUE CROSS BLUE SHIELD