Provider Demographics
NPI:1619914702
Name:BRADLEY J RICHARDSON MD ED D INC
Entity Type:Organization
Organization Name:BRADLEY J RICHARDSON MD ED D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-529-0483
Mailing Address - Street 1:2828 1ST AVE
Mailing Address - Street 2:SUITE 510
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702
Mailing Address - Country:US
Mailing Address - Phone:304-529-0483
Mailing Address - Fax:304-781-2687
Practice Address - Street 1:2828 1ST AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702
Practice Address - Country:US
Practice Address - Phone:304-529-0483
Practice Address - Fax:304-781-2687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004242Medicaid
WV3810004242Medicaid